When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.)

Apply an allergy identification wrist band.

Instruct the client to avoid medication containing milk and eggs.

Enter allergy information in the client's electronic medical record.

Ensure the client's selections from her dietary menu.

Notify the dietary department of the client's egg intolerance.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A: Applying an allergy identification wrist band is an intervention that the nurse should implement, as this can alert other health care providers of the client's allergies and prevent adverse reactions. Therefore, this is a correct choice.

Choice B: Instructing the client to avoid medication containing milk and eggs is not an intervention that the nurse should implement, as this is not a common or relevant source of allergens for this client. This is an incorrect choice.

Choice C: Entering allergy information in the client's electronic medical record is an intervention that the nurse should implement, as this can ensure accurate and updated documentation of the client's allergies and facilitate communication among health care providers. Therefore, this is another correct choice.

Choice D: Ensuring the client's selections from her dietary menu is an intervention that the nurse should implement, as this can help avoid foods that may trigger allergic reactions or intolerance for this client. Therefore, this is another correct choice.

Choice E: Notifying the dietary department of the client's egg intolerance is an intervention that the nurse should implement, as this can help modify or substitute foods that contain eggs for this client. Therefore, this is another correct choice.

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Correct Answer is C

Explanation

Choice A reason: Measuring abdominal girth is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be useful for monitoring fluid status and abdominal distension.

Choice B reason: Assessing perineal area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be important for maintaining hygiene and preventing infection.

Choice D reason: Palpating flank area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be helpful for detecting kidney tenderness or enlargement.

A. Remove the catheter and palpate the client’s bladder for residual distention. B. Allow the bladder to empty completely or up to 1,000 mL of urine. C. Clamp the catheter for thirty minutes and then resume draining. D. Remove the catheter and replace with an indwelling catheter.

Correct Answer is B

Explanation

Choice A: Remove the catheter and palpate the client’s bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.

Choice B: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.

Choice C: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.

Choice D: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.

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Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Correct Answer is B

Explanation

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