Nokea
A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?
- A. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning
- B. Discard urine and container, and restart the 24-hour urine collection tomorrow morning
- C. Discard urine and container, have client void, add urine to new container, and then restart test
- D. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM
Correct Answer: B
Rationale: Discarding a specimen invalidates the 24-hour collection, requiring a restart to ensure accurate results. Adding volume, restarting mid-collection, or relabeling compromise test integrity.
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During report, the nurse is given all of the following information. Which client should the nurse go to first?
- A. A diabetic has a blood sugar of 200.
- B. A client who had abdominal surgery earlier today is complaining of operative site pain.
- C. A client who had abdominal surgery yesterday has crackles on auscultation.
- D. A client who had a thyroidectomy earlier today is complaining of muscle spasms.
Correct Answer: D
Rationale: Muscle spasms post-thyroidectomy suggest hypocalcemia from parathyroid injury, a potentially life-threatening emergency requiring immediate assessment. High glucose, pain, or crackles are less urgent.
The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?
- A. Autonomy
- B. Nonmaleficence
- C. Paternalism
- D. Veracity
Correct Answer: B
Rationale: Nonmaleficence (do no harm) was violated by discharging the client under narcotic influence without ensuring safe transport, leading to harm. Autonomy, paternalism, and veracity are not primarily affected.
The nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches for angina. Which of the following statements by the client would require follow-up?
- A. I can apply a new patch to my arm or chest each day
- B. I should avoid placing the patch over areas with a lot of hair
- C. I should remove the patch at night to prevent tolerance
- D. I will apply the patch only when I experience chest pain
Correct Answer: D
Rationale: Nitroglycerin patches are for angina prevention, applied daily, not as-needed. Rotating sites, avoiding hair, and removing at night (patch-free interval) are correct.
Exhibit 1
Medication administration record
Allergies: No known drug allergies
Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100
Exhibit 2
Laboratory results and reference ranges
Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)
The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?
- A. Administer insulin lispro per protocol and insulin NPH
- B. Contact the client's health care provider
- C. Obtain a urine specimen to check for ketones
- D. Recheck the client's capillary blood glucose level
Correct Answer: B
Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.
The obstetric client is determined to have oligohydramnios. Which fetal anomaly is associated with oligohydramnios?
- A. Diabetes
- B. Renal agenesis
- C. Tracheo-esophageal fistula
- D. Tracheo-esophageal atresia
Correct Answer: B
Rationale: Oligohydramnios, low amniotic fluid, is strongly associated with renal agenesis, as the fetus's kidneys fail to produce urine, a major component of amniotic fluid. Other anomalies listed are less directly related.