The nurse observes the external genitalia of a female client in preparation for inserting an indwelling urinary catheter. At which location should the catheter be inserted? (Mark location on image)

A. Oxygen saturation 95% on room air A SpO2 of 95% is within acceptable limits, especially in a client who is not exhibiting signs of respiratory distress. This does not require immediate investigation, as it is not low enough to be concerning.

B. Bone misalignment: The client’s collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation that needs to be evaluated further to prevent further injury, ensure proper alignment, and determine the need for stabilization or surgical intervention.

C. Swelling at the site of injury: Swelling at the injury site, especially with a history of trauma, could indicate a fracture or soft tissue damage. The nurse should assess the extent of the swelling to rule out internal bleeding, compartment syndrome, or a fracture requiring urgent management.

D. Nausea and fatigue reported by client: Nausea and fatigue can be symptoms of more serious conditions, such as a concussion or internal bleeding, especially given the trauma to the head. These symptoms should be investigated to rule out any neurological or systemic involvement.

E. Decreased range of motion: The client’s decreased range of motion in the left arm, particularly with the reported intense pain, indicates a potential fracture, dislocation, or significant soft tissue injury. This needs to be further assessed to ensure proper treatment and avoid further complications.

F. Intense pain reported by client: The client reports intense pain (10 on a 0 to 10 scale) in the left arm, along with difficulty moving it. This is a critical symptom, suggesting a possible fracture, dislocation, or soft tissue injury that needs to be addressed immediately.

G. Left arm that is cool to touch: Coolness to the touch in the left arm could indicate a lack of adequate blood circulation, potentially from vascular injury or compression. This requires further evaluation to assess for possible arterial injury or compartment syndrome.

G. Blood pressure of 136/90 mm Hg: While 136/90 mm Hg is elevated for a general population, it is not an immediate life-threatening concern in this acute trauma setting. It could be a normal finding for someone with a history of hypertension, or a temporary elevation due to pain and anxiety from the injury.

A. Ask family members to remain with the client in the evenings from 1700 to 2100: While family presence can offer comfort, it is not always feasible and doesn’t directly address the environmental management needed for sundowning behaviors.

B. Administer a prescribed PRN benzodiazepine at the onset of a confused state: Though medications may help in acute cases, routine pharmacologic management is not the first-line intervention due to risks like oversedation and increased fall risk in older adults.

C. Postpone administration of nighttime medications until after 2300: Delaying medications may interfere with sleep hygiene and the efficacy of routine medications that aid in rest or symptom management.

D. Ensure that the client is assigned to a room close to the nurses' station: Proximity to staff allows for more frequent monitoring and faster intervention during episodes of confusion, helping prevent injury and manage behaviors associated with sundowning.