A nurse is obtaining a 24-hour urine specimen collection from the patient. Which action should the nurse take?

Testing the urine sample with a reagent strip by dipping in the urine

Withholding all patient medications for the day

Asking the patient to void and discarding that urine to start the collection

Irrigating the sample as needed with sterile solution

Answer and Explanation

The Correct Answer is C

Choice A reason: Testing the urine sample with a reagent strip is not a standard procedure for a 24-hour urine collection. This method is used for spot urine tests to assess parameters like glucose or protein but does not ensure accurate measurement of total urine output or analytes over 24 hours. It introduces potential contamination and is irrelevant to the collection process, which focuses on volume and composition over time.

Choice B reason: Withholding all patient medications is unnecessary and potentially harmful for a 24-hour urine collection. Medications may influence urine composition, but the collection aims to reflect the patient’s normal physiological state, including medication effects. Disrupting medication schedules could alter metabolic or renal function, skewing results and compromising patient health.

Choice C reason: Asking the patient to void and discard the initial urine marks the start of the 24-hour collection period. This ensures all subsequent urine reflects the exact 24-hour timeframe, providing accurate data on volume, electrolytes, and other analytes. This step establishes a clear baseline, preventing inclusion of urine from an undefined prior period.

Choice D reason: Irrigating the sample with sterile solution is inappropriate for a 24-hour urine collection. Adding any solution would dilute the sample, altering its concentration and volume, thus invalidating results for tests like creatinine clearance or protein excretion. The collection requires untouched urine to maintain analytical integrity.

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Correct Answer is D

Explanation

Choice A reason: Green liquid stool in a colostomy pouch is often benign, resulting from diet (e.g., green vegetables) or medications. In an 80-year-old, this is not immediately concerning unless accompanied by systemic symptoms like fever or pain.

Choice B reason: Slight bleeding when wiping a colostomy is common, especially in an 18-year-old with a new stoma, due to fragile tissue. It warrants monitoring but is not as concerning as signs of poor stoma viability.

Choice C reason: A red, moist colostomy in a 45-year-old indicates a healthy, well-perfused stoma, which is normal post-placement. This is an expected finding and does not raise immediate concern compared to abnormal stoma appearance.

Choice D reason: A pale pink/purple colostomy suggests poor perfusion or ischemia, especially in a 55-year-old. This abnormal color, even with moisture, indicates potential stoma necrosis, requiring urgent assessment to prevent complications like tissue death or infection.

A. Stop the enema and document that the client did not tolerate the procedure. B. Lower the height of the solution container. C. Encourage the client to bear down. D. Allow the client to expel some fluid before continuing.

Correct Answer is B

Explanation

Choice A reason: Stopping the enema entirely is premature and unnecessary for cramping, which is a common response to rapid fluid instillation. Documentation of intolerance is only appropriate if the procedure cannot be completed after attempting adjustments. This action fails to address the cramping’s cause, potentially delaying constipation relief and patient comfort.

Choice B reason: Lowering the solution container reduces the flow rate of the enema, decreasing intraluminal pressure in the colon. Cramping often results from rapid fluid instillation stretching the bowel. Slowing the flow allows the colon to accommodate the fluid, alleviating discomfort while continuing the procedure effectively.

Choice C reason: Encouraging the client to bear down is inappropriate as it may cause premature expulsion of the enema fluid, reducing its effectiveness in relieving constipation. Bearing down increases intra-abdominal pressure, potentially exacerbating cramping rather than alleviating it, and does not address the underlying cause of discomfort from fluid instillation.

Choice D reason: Allowing the client to expel fluid prematurely interrupts the enema’s purpose of softening stool and stimulating bowel movement. While it may temporarily relieve cramping, it reduces the procedure’s efficacy, potentially requiring a repeat enema, which increases patient discomfort and procedural risks like rectal irritation.

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A nurse is obtaining a 24-hour urine specimen collection from the patient. Which action should the nurse take?

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