When initiating a 24 hour urine collection, which action should the practical nurse (PN) take?
Maintain sterile technique during specimen collection.
Assist the client to cleanse the perineal area prior to voiding.
Instruct the client to discard the first voided specimen.
Insert an indwelling urinary catheter.
The Correct Answer is C
A. Maintain sterile technique during specimen collection: Sterile technique is required for urine cultures, not for 24-hour urine collections. For a timed urine collection, clean collection techniques are sufficient to accurately measure excretion over a full day.
B. Assist the client to cleanse the perineal area prior to voiding: While perineal hygiene is important, it is not the primary step when starting a 24-hour urine collection. The critical action is ensuring that the first void is discarded to properly begin timing the collection period.
C. Instruct the client to discard the first voided specimen: The first void is discarded to ensure the collection accurately measures substances excreted during the full 24-hour period. Timing officially starts after discarding the initial urine, and every subsequent void must be collected.
D. Insert an indwelling urinary catheter: Inserting an indwelling catheter is unnecessary unless the client is unable to void independently. Most 24-hour urine collections are performed using normal voiding and collection into a clean container.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Require family members and visitors to wear a mask and gown when visiting the client: Masks and gowns are needed in healthcare settings to prevent cross-contamination, but at home, strict use of personal protective equipment (PPE) is not typically necessary for a draining wound unless there is high-risk exposure. Basic hygiene is usually sufficient.
B. Have the client stay in a room separate from the family with the door closed: Isolation at home is generally not necessary unless the infection is highly contagious through casual contact. Emphasis should instead be placed on good wound care and proper hygiene practices.
C. Use paper plates and disposable utensils for the client's meals and snacks: There is no need to use disposable eating utensils. Normal dishwashing practices are adequate to prevent the spread of infection in a home environment, as long as proper cleaning is maintained.
D. Place soiled dressings in a plastic bag that can be tightly secured for disposal: Proper disposal of contaminated dressings in a sealed plastic bag prevents leakage and minimizes exposure to infectious materials. This practice protects household members from accidental contact with wound drainage.
Correct Answer is B
Explanation
A. Rectus abdominis: The rectus abdominis is a muscle in the abdomen, not the thigh. It is not used for intramuscular injections, as it does not provide the necessary mass or safe anatomical location for such injections.
B. Rectus femoris: The rectus femoris is located in the mid anterior thigh and is a common site for intramuscular injections, especially when other sites are not ideal. It provides easy access, sufficient muscle mass, and fewer major nerves or blood vessels.
C. Gluteus medius: The gluteus medius is located in the upper outer quadrant of the buttock, commonly used for dorsogluteal or ventrogluteal injections, not for injections into the anterior thigh.
D. Gluteus maximus: The gluteus maximus forms the bulk of the buttocks and is used for dorsogluteal injections. It is not located in the anterior thigh and is associated with greater risk of hitting major nerves like the sciatic nerve.
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