The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

Start the collection time now and stop the collection the next day at the same time.

Provide catheter care at the urinary site to prevent contamination of the specimens.

Clamp the catheter to control urine flow during the collection period.

Label the collection container with the client’s name and start time.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting the collection time after emptying the bag ensures an accurate 24-hour urine sample, critical for diagnostic tests like creatinine clearance. This defines the collection period, per laboratory and diagnostic specimen collection protocols in nursing practice.

Choice B reason: Catheter care prevents infection but is not the most critical step for initiating a 24-hour collection. Starting the collection time ensures accurate timing, essential for valid results, per urinary specimen collection and infection control standards in nursing.

Choice C reason: Clamping the catheter is inappropriate, as it disrupts continuous urine flow, skewing the 24-hour collection. Starting the collection time ensures accurate sampling, critical for diagnostic accuracy, per urinary catheter management and laboratory protocols in nursing practice.

Choice D reason: Labeling the container is important but secondary to starting the collection time, which defines the 24-hour period for accurate results. Timing ensures valid diagnostic data, per specimen collection and laboratory standards in nursing practice for urine collections.

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Correct Answer is B

Explanation

Choice A reason: Cutting nails and soaking in antibiotic solution risks infection in insulin-dependent diabetes, where neuropathy impairs sensation and healing. Thick nails may be fungal, needing specialist care. Checking for injuries and referring to a podiatrist ensures safe management, preventing ulcers in high-risk diabetic feet.

Choice B reason: Checking for cuts assesses diabetic foot risk, as neuropathy and poor glycemic control impair healing. Thick nails piercing toes require podiatrist trimming to prevent trauma or infection. Referral ensures expert care, addressing pathophysiological risks of neuropathy and vascular impairment, preventing serious complications like ulcers.

Choice C reason: Soaking and cutting nails is risky in diabetes, as neuropathy increases injury risk, and warm water may introduce infection in unnoticed wounds. Fungal nails need specialist care. Referral to a podiatrist ensures safe trimming, preventing infection in compromised feet, making this action unsafe.

Choice D reason: Advising lotion to soften nails does not mitigate injury risk from trimming thick nails in diabetes. Neuropathy and poor healing increase infection risk from errors. Specialist referral ensures safe nail management, preventing trauma or ulceration, critical in diabetic foot care due to vascular deficits.

A. Connect the nasogastric tube to suction as prescribed. B. Clamp the nasogastric tube and contact the healthcare provider. C. Immediately remove and then reinsert the nasogastric tube. D. Connect the nasogastric tube to high continuous suction.

Correct Answer is B

Explanation

Choice A reason: Connecting to suction is inappropriate, as “coffee ground” drainage indicates upper GI bleeding, likely from an ulcer. Suction could worsen bleeding by traumatizing the site. Clamping and notifying the provider ensure assessment, preventing further hemorrhage or complications like perforation in this critical scenario.

Choice B reason: “Coffee ground” drainage suggests oxidized blood from upper GI bleeding (e.g., gastritis). Clamping prevents irritation or bleeding exacerbation, and contacting the provider ensures urgent evaluation, possibly via endoscopy or proton pump inhibitors, addressing the bleeding source to stabilize the client and prevent shock.

Choice C reason: Removing and reinserting the tube risks further trauma to the bleeding site, as “coffee ground” drainage indicates active hemorrhage. Repeated insertion may dislodge clots, worsening bleeding. Clamping and notifying the provider prioritize safety, allowing diagnostic and therapeutic interventions for the underlying cause.

Choice D reason: High continuous suction is contraindicated, as “coffee ground” drainage signals GI bleeding, and aggressive suction could dislodge clots, increasing hemorrhage. Clamping and contacting the provider ensure controlled management, preventing complications like hypovolemic shock, making this action harmful and inappropriate.

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The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

Correct Answer is B

Explanation

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of “coffee ground” drainage. Which action should the nurse implement?

Correct Answer is B

Explanation

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