Nokea
A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?
- A. At the beginning of the collection time, urinate and then discard the urine.
- B. Keep the collection container at room temperature.
- C. Save each urine collection in a separate container.
- D. At the end of the collection time, urinate and save the urine in a separate container.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Urinating and discarding the first urine sample helps ensure that the 24-hour collection period begins accurately. This initial voiding clears out any urine that has been in the bladder prior to the start of the collection. This step is crucial to obtain an accurate measurement of substances excreted over the 24-hour period.
Summary:
B: Keeping the collection container at room temperature is not crucial for accurate urine collection.
C: Saving each urine collection in a separate container may lead to inaccuracies in the final analysis.
D: Urinating and saving the final urine sample separately at the end of the collection period may skew the results.
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A nurse is reinforcing teaching with a client who has a respiratory infection. The nurse should have the client lie on his left side with pillows elevating the right side of his chest to help mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right upper lobe
Correct Answer: D
Rationale: Positioning helps mobilize secretions from specific lung segments, aiding in pulmonary hygiene.
A nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms. Which of the following dietary elements should the nurse instruct the client to limit?
- A. Fat
- B. Water
- C. Calcium
- D. Vitamin E
Correct Answer: A
Rationale: A diet low in fat has been shown to help reduce fibrocystic breast pain and discomfort.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate assessment of the client's heart rate. It allows for any irregularities or fluctuations in the pulse to be detected.
Choice B is incorrect as using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, should be used to listen to the apical pulsations for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the client's skin can create artifact noise and interfere with accurate auscultation.
A nurse is collecting data from the daughter of an older adult client. Which of the following statements by the daughter is a priority to the nurse?
- A. My mother is unable to bathe herself.'
- B. We sit outside every afternoon.'
- C. We buy the prescriptions we can afford.'
- D. My mother seems depressed.'
Correct Answer: C
Rationale: Financial constraints affecting medication adherence pose an immediate health risk and require intervention.
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
- A. Collect urine from the catheter's port.
- B. Use a sterile specimen container.
- C. Use sterile water to inflate the balloon.
- D. Instruct the client to clean from front to back with an antiseptic solution.
Correct Answer: B
Rationale: The correct answer is B: Use a sterile specimen container. This is crucial to prevent contamination of the urine sample, ensuring accurate culture and sensitivity results. Sterile container minimizes the risk of introducing bacteria from the environment. Option A is incorrect because collecting urine from the catheter's port may introduce contaminants. Option C is incorrect as sterile water is not used to inflate the balloon but rather sterile saline. Option D is incorrect because cleaning from front to back is not relevant to obtaining a urine specimen via catheterization.