A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

Correct Answer: A

Rationale: Discarding the first void starts a fresh 24-hour period. Adding it (B) skews results. Warmth (C) and timing (D) are secondary.

Correct Answer: C

Rationale: A respiratory rate of 8 is abnormally low (hypoventilation). Checking pulse oximetry first assesses oxygenation status, guiding further actions like oxygen administration or physician notification.

Correct Answer: B

Rationale: Accessory muscle use (e.g., neck, shoulders) suggests respiratory distress, as the patient struggles to breathe, not normal breathing, improved oxygenation, or mere fatigue.

Correct Answer: A

Rationale: Anemia reduces hemoglobin, the oxygen-carrying component of blood, directly impairing oxygenation, unlike blood pressure, airway issues, or fluid overload.

Correct Answer: A

Rationale: Carbon monoxide poisoning causes cherry-red lips due to carboxyhemoglobin formation, impairing oxygen delivery. This is a specific, priority sign over fever, tachycardia, or hypotension.