A nurse is reviewing urinary laboratory results. Which findings should prompt the nurse to follow up?

Choice A rationale

The nurse should plan to refrigerate the urine during the collection time period. This is because the urine needs to be kept cool to prevent the breakdown of certain analytes that might be measured in the urine.

Choice B rationale

The nurse should not discard the client’s last void at the end of the collection time period. The last voided specimen should be included in the collection to ensure that the 24-hour collection is complete.

Choice C rationale

The nurse should not include toilet paper with the collected urine. Toilet paper could contaminate the urine sample and interfere with the accuracy of the test results.

Choice D rationale

The nurse should not save the first void at the start of the collection time period. The first voided specimen should be discarded, and the collection should start with the next void.

The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.

The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.