A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

Notify the charge nurse of the problem.

Notify the healthcare provider of the situation.

Discard the urine and start another 24-hour period.

Add another hour to the urine collection period.

Answer and Explanation

The Correct Answer is C

A.   While it’s important to inform the charge nurse of any issues with the collection process, this action alone does not address the core problem of the collection being compromised. The charge nurse may offer guidance or assist in deciding the next steps, but the primary focus should be on correcting the collection process to ensure accurate results.
B.   Notifying the healthcare provider can be important, especially if the results of the 24-hour urine collection are critical to the client’s diagnosis or treatment plan. However, it is usually more efficient to first address the issue of the collection itself and then inform the healthcare provider about the results of these corrective actions.
C.   This is the most appropriate action when a mistake occurs in the collection process, such as flushing a voided sample. The integrity of the collection is compromised, and starting a new 24-hour collection period ensures that all samples are accounted for and that the results will be accurate.
D.   Adding extra time to the urine collection period does not compensate for the missed sample. The accuracy of the collection depends on having all urine samples from the full 24-hour period.

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Correct Answer is D

Explanation

A. Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B. Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C. A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D. Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

A. Decrease the rate of the feeding by half. B. Observe for an allergic reaction to the formula. C. Hang a new bag of the enteral formula. D. Stop the tube feeding and assess the client.

Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

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A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

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