A nurse is delegating the collection of urinary output to an assistive personnel (AP). What should the nurse tell the AP to do while measuring the urine?

Tell the client to wash the urethra before voiding.

Wear gloves when handling a client's urine.

Use a clean measuring cup for each voiding

Compare the amount of output with intake

Answer and Explanation

The Correct Answer is B

a) Tell the client to wash the urethra before voiding: While it is important for patients to maintain hygiene, instructing them to wash the urethra is not a necessary step for APs collecting urine output. It is important for the AP to focus on measuring output.

b) Wear gloves when handling a client's urine: The AP should always wear gloves when handling bodily fluids, including urine, to prevent contamination and the spread of infection.

c) Use a clean measuring cup for each voiding: Using a clean measuring cup is important for accurate measurements, but the focus here should be on wearing gloves and correctly measuring the urine.

d) Compare the amount of output with intake: Comparing output with intake is the responsibility of the nurse, not the AP. The AP should focus on collecting and accurately measuring the urine output.

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Correct Answer is D

Explanation

a) School-age child: While a school-age child is at risk for dehydration, their fluid and electrolyte imbalance risk is less than that of an infant due to greater reserve and more effective compensatory mechanisms.

b) Adolescent: Similar to the school-age child, an adolescent is at lower risk for severe fluid and electrolyte imbalances due to a better-developed system to handle fluid loss.

c) Young adult: While diarrhea can lead to dehydration in young adults, they are generally more capable of compensating for mild to moderate fluid losses compared to infants.

d) Infant: Infants are at the highest risk for severe fluid and electrolyte imbalance due to their smaller body size, higher fluid turnover, and less efficient compensatory mechanisms. Dehydration can develop quickly in infants.

A. Mechanically altered B. Clear liquid C. Honey like liquids D. Full liquid

Correct Answer is A

Explanation

a) Mechanically altered: A mechanically altered diet includes foods that are chopped, mashed, or ground, which makes them easier to chew and swallow, especially for patients with poorly fitting dentures who may have difficulty chewing solid foods.

b) Clear liquid: While a clear liquid diet may be appropriate for certain conditions, it does not provide enough nutrition or texture modifications for a patient with denture issues who needs something more substantial.

c) Honey-like liquids: Honey-like liquids are thicker than normal liquids and are used for patients with swallowing difficulties, not for those with poorly fitting dentures.

d) Full liquid: A full liquid diet consists of liquids that are in a liquid form at room temperature, but it may not address the chewing issues a patient with dentures might face with certain foods.

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A nurse is delegating the collection of urinary output to an assistive personnel (AP). What should the nurse tell the AP to do while measuring the urine?

Nursing Test Bank

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