The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Choice A reason: This is not the most important assessment because abdominal girth is not a reliable indicator of fecal impaction. Abdominal girth can vary depending on the client's body type, fluid status, and other factors.

Choice B reason: This is also not the most important assessment because breath sounds are not directly related to fecal impaction. Breath sounds can be affected by respiratory conditions, smoking, allergies, and other factors.

Choice C reason: This is another incorrect choice because bowel sounds are not the most important assessment either. Bowel sounds can be diminished or absent in clients with fecal impaction, but they can also be altered by other gastrointestinal disorders, medications, and dietary factors.

Choice D reason: This is the correct choice because vital signs are the most important assessment prior to initiating digital removal of a fecal impaction. Vital signs can indicate the client's hemodynamic status, pain level, and risk of complications such as vagal stimulation, perforation, or infection. The nurse should monitor the client's blood pressure, pulse, respirations, and temperature before, during, and after the procedure.

Choice A reason:Hand hygiene is the foundation of Standard Precautions and the single most effective action to prevent transmission of infectious agents. Performing handwashing or using an alcohol‑based hand rub immediately before preparing or administering an injection removes transient microorganisms acquired from touching surfaces and protects both the client and the environment from contamination

Choice B reason:While wearing gloves during handling and disposal of contaminated sharps is recommended whenever there is potential contact with blood or body fluids, it is a secondary barrier. Reliance on gloves alone is insufficient because gloves can have micro‑perforations and are removed after use, making hand hygiene before and after glove use the priority

Choice C reason: Donning a face mask before administering the medication is not a necessary action to indicate an understanding of standard precautions. A face mask is only required when there is a risk of droplet transmission of infectious agents, such as when caring for a client with respiratory infections. It is not needed for self-administration of medications, unless the medication is aerosolized or nebulized.

Choice D reason: Removing the needle before discarding used syringes is not a safe action to indicate an understanding of standard precautions. It increases the risk of needle-stick injuries and contamination. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.