Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?
Observe insertion site.
Palpate flank area.
Measure abdominal girth.
Assess perineal area.
The Correct Answer is A
Choice A reason: Observing the insertion site of the suprapubic catheter is an essential assessment for the home health nurse, as this can help detect any signs of infection, inflammation, or leakage. Therefore, this is the correct choice.

Choice B reason: Palpating the flank area is not a necessary assessment for the home health nurse, as this is not related to the suprapubic catheter. This is a distractor choice.
Choice C reason: Measuring abdominal girth is not a relevant assessment for the home health nurse, as this is not affected by the suprapubic catheter. This is another distractor choice.
Choice D reason: Assessing the perineal area is not an important assessment for the home health nurse, as this is not involved in the suprapubic catheter. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,A,C,D
Explanation
The correct order is:
- Note date and time of the behavior.
- Discuss the issue privately with the UAP.
- Plan for scheduled break times.
- Evaluate the UAP for signs of improvement.
Here are the reasons for this order:
- Note date and time of the behavior. This should be done first, as it can provide objective evidence of the UAP's behavior and its impact on patient care and staff workload. The unit manager should document any incidents or complaints related to the UAP's behavior in a factual manner.
- Discuss the issue privately with the UAP. This should be done second, as it can provide an opportunity for feedback and clarification. The unit manager should use a respectful and professional tone, and explain how the UAP's behavior affects patient safety and staff morale. The unit manager should also listen to any concerns or challenges that the UAP may have, and offer support or guidance as needed.
- Plan for scheduled break times. This should be done third, as it can provide a solution or prevention strategy for future occurrences. The unit manager should work with the UAP and other staff members to ensure that there are adequate breaks and coverage for patient care. The unit manager should also review any policies or procedures related to break times and staff attendance.
- Evaluate the UAP for signs of improvement. This should be done last, as it can provide a measure of effectiveness and accountability. The unit manager should monitor and document any changes in the UAP's behavior, performance, or attitude. The unit manager should also provide positive reinforcement or corrective action as appropriate.
Correct Answer is ["B","C","D","F"]
Explanation
Choice A reason: Alcohol consumption will not produce vascular changes is incorrect information. Alcohol consumption can increase blood pressure by causing vasoconstriction, fluid retention, and interference with antihypertensive medications. The nurse should advise the client to limit alcohol intake to no more than one drink per day for women and two drinks per day for men.
Choice B reason: Sodium intake can be regulated by limiting canned foods in the diet is correct information. Sodium intake can increase blood pressure by causing fluid retention and increasing vascular resistance. The nurse should advise the client to limit sodium intake to no more than 2300 mg per day and avoid processed foods that are high in sodium, such as canned foods, soups, sauces, and snacks.
Choice C reason: Salt substitutes can help with maintaining a healthy diet is correct information. Salt substitutes can reduce sodium intake by replacing sodium chloride with potassium chloride or other minerals. The nurse should advise the client to use salt substitutes sparingly and consult with their healthcare provider before using them if they have kidney disease or take certain medications that affect potassium levels.
Choice D reason: Weight management is promoted by taking daily walks for thirty minutes is correct information. Weight management can lower blood pressure by reducing body fat, improving blood circulation, and enhancing insulin sensitivity. The nurse should advise the client to maintain a healthy weight and engage in moderate physical activity for at least 150 minutes per week.
Choice E reason: Blood pressure readings should be taken at noontime is incorrect information. Blood pressure readings should be taken at different times of the day, preferably in the morning and evening, to monitor fluctuations and trends. The nurse should advise the client to use a home blood pressure monitor that is accurate and calibrated and follow proper techniques for measuring blood pressure.
Choice F reason: Uncontrolled hypertension can lead to renal damage is correct information. Uncontrolled hypertension can damage the blood vessels in the kidneys, leading to reduced kidney function and chronic kidney disease. The nurse should advise the client to follow their prescribed treatment plan and monitor their blood pressure regularly.
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