A nurse is instructing a female client on obtaining a clean catch urine sample. Which of the following statements by the client indicates an understanding of the teaching?

"I should not collect a urine sample when I am menstruating."

"I need to urinate a small amount in the toilet before collecting the sample."

"I should let the urine cool to room temperature before sending it to the lab."

"I will wipe from the back to front with the cleansing cloth."

Answer and Explanation

The Correct Answer is B

A. While menstruation can potentially contaminate the sample, it is still possible to collect a clean catch sample during menstruation if proper technique is used; thus, this statement is not entirely accurate.
B. This is the proper clean catch technique—starting the stream helps flush out any contaminants from the urethra, and then the midstream portion is collected for testing.
C. Urine samples should be sent to the lab promptly while still fresh, or refrigerated if there will be a delay. Letting it cool to room temperature can alter test results.
D. Wiping from front to back is correct to reduce contamination from the perineal area; wiping from back to front increases the risk of introducing bacteria from the rectal area.

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Correct Answer is D

Explanation

A. Bilateral weakness may occur depending on the injury location but is not a primary or early sign of increased intracranial pressure (ICP).
B. Hypotension is generally not associated with increased ICP; instead, hypertension is more common as part of Cushing’s response.
C. Tachypnea is not a typical manifestation of increased ICP; irregular or decreased respirations are more common.
D. Changes in consciousness, such as lethargy, confusion, or coma, are key early indicators of increased ICP due to pressure on brain structures and impaired cerebral perfusion

Correct Answer is ["54"]

Explanation

Lower limbs= Anterior (18) + posterior (18)

Posterior trunk= 18

Total= 18+18+18

TBSA= 54%

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A nurse is instructing a female client on obtaining a clean catch urine sample. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?

Correct Answer is ["54"]

Explanation

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