A nurse is preparing to obtain a 24-hr urine collection from a client.
Which of the following actions should the nurse plan to take?

Discard the client's last void at the end of the collection time period.

Include toilet paper with the collected urine.

Save the first void at the start of the collection time period.

Refrigerate the urine during the collection time period.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Discard the client's last void at the end of the collection time period. This choice is not appropriate. When conducting a 24-hour urine collection, it's essential to include all urine produced during the specified time frame. Discarding the last void would result in an incomplete and inaccurate collection.

Choice B rationale:

Include toilet paper with the collected urine. This choice is also incorrect. Toilet paper is not typically included in a 24-hour urine collection. The purpose of this collection is to accurately measure substances excreted by the kidneys over a specific time period. Toilet paper is not part of this measurement and should not be included.

Choice D rationale:

This helps prevent the breakdown of certain substances and ensures the sample's accuracy. Failure to refrigerate the urine can lead to inaccurate test results. Now, let's discuss the rationale for the correct answer, choice C:

Choice C rationale:

The first void at the beginning of the collection period is typically discarded, as it represents the urine that was in the bladder before the timed collection started. This helps ensure that the collection is accurate and only includes urine produced during the specified 24-hour period. It's important to follow this protocol to obtain reliable test results.

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Correct Answer is B

Explanation

Choice A rationale:

Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.

Choice C rationale:

Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.

Choice D rationale:

An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.

Choice B rationale:

An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.

A. The client has peripheral vascular disease. B. The client has urinary incontinence. C. The client takes anticoagulant medications. D. The client is underweight.

Correct Answer is C

Explanation

Choice A rationale:

Peripheral vascular disease does not directly place the client at a higher risk for an incisional hematoma. While it is a vascular condition, the use of anticoagulant medications is a more significant risk factor for bleeding complications.

Choice B rationale:

Urinary incontinence is not directly related to an increased risk of incisional hematoma. Incontinence is a separate issue and does not influence surgical outcomes in the context of hematoma formation.

Choice C rationale:

Taking anticoagulant medications is a significant risk factor for incisional hematoma. Anticoagulants reduce the blood's ability to clot, which can lead to excessive bleeding at the surgical site and the formation of hematomas.

Choice D rationale:

Being underweight is not a primary risk factor for incisional hematoma. While poor nutrition and overall health can influence wound healing, anticoagulant use is a more direct concern for hematoma formation in surgical patients.

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A nurse is preparing to obtain a 24-hr urine collection from a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

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A nurse is preparing to obtain a 24-hr urine collection from a client.
Which of the following actions should the nurse plan to take?