1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the
following statements indicates an understanding of the teaching?
a. I had a bowel movement, but I was able to save the urine – shoul
...
1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the
following statements indicates an understanding of the teaching?
a. I had a bowel movement, but I was able to save the urine – should be free of
feces
b. I have a specimen in the bathroom from about 30 minutes ago- Client should
place any urine in the container immediately and keep it on ice or in the fridge.
c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24 hr
urine collection, the client should discard the first voiding and save all
subsequent voiding.
d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified
amount
2. A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has
developed thrombophlebitis?
a. Bladder distention – urinary retention which causes bladder distension is a
common complication of bed rest due to a loss of muscle tone in the bladder
and detrusor muscles
b. Decreased blood pressure – client on bed rest can develop postural hypotension.
Drop in BP when the client moves from a lying to a sitting position. Nurse should
assess for pulse rate and dizziness.
c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations of
thrombophlebitis, a common complication of immobility
d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis.
Constipation is common complication of immobility.
3. A nurse manager is overseeing the care on a unit. Which of the following situations
should the nurse manager identify as a violation of HIPAA guidelines?
a. A nurse who is caring for a client reviews the client's medical chart with the
nursing student who is working with the nurse – any healthcare professional
directly caring for a client has access to the medical information.
b. A nurse asks a nurse from another unit to assist with her documentation – only
health care professionals directly caring for a client may access medical
information.
c. A nurse who is caring for a client returns a call to the client's durable power of
attorney for healthcare designee to discuss the client's care – The person the
durable power of attorney for health care designates has a legal right to
information about the client’s care.
d. A nurse discusses the client's status with the physical therapist that is caring for
the client at the client's bedside – any healthcare professional directly caring for
a client has access to the medical information.
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