A nurse is reinforcing teaching with a client who has gestational hypertension about collecting a 24-hr urine specimen for protein. Which of the following statements should the nurse include in the teaching?
"Cleanse your perineum with povidone-iodine prior to collecting each urine specimen."
"You should start the 24-hour collection with your first urination."
"You should record the time on the collection container of any missed urine specimens."
"Do not add a urine specimen to the collection container if it contains stool
The Correct Answer is C
A) Incorrect- Cleansing the perineum with povidone-iodine is not relevant to the collection process.
B) Incorrect- The 24-hour collection should start with the first-morning urination, not with any random urination.
C) Correct - Recording the time on the collection container for any missed urine specimens is important for accurate measurement.
D) Incorrect- Stool should not be added to the urine collection container, but this is not the most important point to emphasize in this teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F","H"]
Explanation
A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.
Correct Answer is D
Explanation
The correct answer is d. "I may develop discoloration on my cheeks from hormonal changes."
Choice a rationale:
- Statement:"I should expect to have burning when I urinate during the third trimester."
- Rationale:This statement is incorrect.Burning during urination is not a normal physiological change of pregnancy.It may be a sign of a urinary tract infection (UTI),which is a common infection during pregnancy.If a pregnant client experiences burning during urination,she should report it to her healthcare provider for evaluation and treatment.
Choice b rationale:
- Statement:"I may have an infection if I develop a dark line in the middle of my abdomen."
- Rationale:This statement is incorrect.A dark line in the middle of the abdomen,known as the linea nigra,is a normal physiological change of pregnancy.It is caused by hormonal changes that increase melanin production in the skin.The linea nigra typically appears in the second trimester and fades after delivery.
Choice c rationale:
- Statement:"I should expect my fingers and face to be swollen."
- Rationale:This statement is partially correct.Some swelling in the hands and face is common during pregnancy,especially in the third trimester.This is due to fluid retention caused by hormonal changes.However,excessive swelling,particularly in the hands and face,can be a sign of preeclampsia,a serious pregnancy complication.It's important to report any significant swelling to a healthcare provider.
Choice d rationale:
- Statement:"I may develop discoloration on my cheeks from hormonal changes."
- Rationale:This statement is correct.Hormonal changes during pregnancy can cause a variety of skin changes,including melasma,which is a brownish discoloration that often appears on the cheeks,forehead,and nose.Melasma is more common in women with darker skin tones and usually fades after delivery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
