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: Observing insertion site is an essential assessment for a client who has a suprapubic catheter. The insertion site is located in the lower abdomen, where urine drains from an opening in the bladder through a catheter into a drainage bag. The nurse should inspect the site for signs of infection, inflammation, bleeding, or leakage. The nurse should also clean the site with soap and water and apply a sterile dressing as needed.
Choice B: Palpating flank area is not a relevant assessment for a client who has a suprapubic catheter. The flank area is located on the sides of the back, where the kidneys are located. Palpating the flank area can detect tenderness or pain that may indicate kidney infection or stones, but it does not provide information about the suprapubic catheter or its function.
Choice C: Measuring abdominal girth is not a relevant assessment for a client who has a suprapubic catheter. The abdominal girth is the circumference of the abdomen at the level of the umbilicus. Measuring abdominal girth can detect changes in fluid balance, ascites, or bowel obstruction, but it does not provide information about the suprapubic catheter or its function.
Choice D: Assessing perineal area is not a relevant assessment for a client who has a suprapubic catheter. The perineal area is located between the anus and the genitals. Assessing perineal area can detect signs of infection, irritation, or injury in the genital or anal regions, but it does not provide information about the suprapubic catheter or its function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice B is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause portal hypertension, which is an increased pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can lead to ascites, which is an accumulation of fluid in the abdominal cavity. The nurse should measure and record the abdominal girth daily and report any significant changes.
Choice C is correct because reporting serum albumin and globulin levels is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can impair the synthesis of proteins, such as albumin and globulin, which are essential for maintaining fluid balance, immune function, and blood clotting. The nurse should monitor and report the serum albumin and globulin levels and administer supplements or transfusions as prescribed.
Choice D is correct because noting signs of bleeding and edema is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause coagulopathy, which is a disorder of blood clotting, due to reduced production of clotting factors and increased consumption of platelets. Coagulopathy can lead to bleeding from various sites, such as the gums, nose, esophagus, stomach, or rectum. The nurse should observe and report any signs of bleeding and apply pressure or bandages as needed. Cirrhosis of the liver can also cause hypoalbuminemia, which is a low level of albumin in the blood, due to decreased synthesis or increased loss of albumin. Hypoalbuminemia can lead to edema, which is swelling caused by fluid retention in the tissues. The nurse should assess and report any signs of edema and elevate the affected limbs or apply compression stockings as indicated.
Choice E is correct because limiting fluid intake to 1500 mL daily is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Fluid restriction can help prevent or reduce ascites and edema by decreasing the fluid load on the circulatory system and the kidneys. The nurse should measure and record the fluid intake and output and educate the client on how to limit their fluid intake.
Choice A is incorrect because providing a diet low in phosphorus is not a specific intervention for a client with cirrhosis of the liver and end stage liver disease. A diet low in phosphorus may be indicated for clients with chronic kidney disease or hyperphosphatemia, but not for clients with cirrhosis of the liver. The nurse should provide a diet that is high in calories, carbohydrates, and protein, but low in sodium, fat, and alcohol for clients with cirrhosis of the liver.
Correct Answer is C
Explanation
Choice A: Yellow-tinged sputum is not a critical finding for the nurse to report, as this is a common sign of pneumonia and does not indicate an adverse reaction to meropenem. This is a distractor choice.
Choice B: Nausea and headache are not urgent findings for the nurse to report, as these are mild side effects of meropenem and can be managed with supportive measures. This is another distractor choice.
Choice C: Watery diarrhea is an important finding for the nurse to report, as this can indicate a serious complication of meropenem, such as Clostridioides difficile infection, which can cause severe dehydration, electrolyte imbalance, and sepsis. Therefore, this is the correct choice.
Choice D: Increased fatigue is not a significant finding for the nurse to report, as this can be related to the client's underlying condition and does not suggest a problem with meropenem. This is another distractor choice.
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