A nurse is caring for a client who has a prescription for warfarin.

Which of the following laboratory tests should the nurse monitor?

Choice A Reason:

Recording blood glucose levels during a 24-hour creatinine clearance test is not typically necessary for this test. This test primarily measures kidney function, not blood glucose levels.

Choice B Reason:

"You can begin collection of urine after discarding your first morning void." When conducting a 24-hour creatinine clearance test, the client should begin the collection of urine after discarding their first morning void. This helps ensure that the urine collected during the test is a continuous sample that includes both daytime and nighttime urine output. The client should discard the first void of the day but then collect all urine voided for the next 24 hours, including the first void of the following morning.

Choice C Reason:

Eating a protein-rich diet during the collection period can affect the accuracy of the test results, as it may increase creatinine excretion. The client should follow the healthcare provider's instructions regarding dietary restrictions.

Choice D Reason:

Cleansing the perineal area with an antiseptic towel each time before voiding is not typically required for this test. It is more important to ensure that all urine is collected and that the collection container is stored properly to prevent contamination.

Choice A Reason:

Removing personal protective equipment (PPE) after leaving the client's room is correct, but it should be done in a way that minimizes the risk of contamination. Proper doffing of PPE is essential to prevent self-contamination.

Choice B Reason:

Wear a gown when assisting the client with personal hygiene. When caring for a client with methicillin-resistant Staphylococcus aureus (MRSA) in a long-term care facility, wearing a gown when assisting the client with personal hygiene is an important infection control measure. MRSA can be transmitted through direct contact with contaminated surfaces or skin, so wearing a gown can help prevent the spread of the bacteria from the client to the healthcare provider's clothing.

Choice C Reason:

Ensuring that negative air pressure is active for the client's room is not typically necessary for MRSA precautions. Negative air pressure rooms are often used for clients with airborne infectious diseases, such as tuberculosis.

Choice D Reason:

Restricting the client's visitors may be necessary in some cases, especially if there is a concern about the potential spread of MRSA to vulnerable individuals. However, visitor restrictions should be implemented based on the facility's policies and guidelines, and they should be communicated clearly to visitors and family members.