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
Explanation
Choice B is correct because assessing the DTRs of a pregnant client with an elevated blood pressure can help detect signs of preeclampsia, a serious complication of pregnancy that can cause seizures, organ damage, and fetal death. Preeclampsia can cause hyperreflexia, which is an exaggerated response of the DTRs.
Choice A is incorrect because ankle edema is not a reliable indicator of preeclampsia and does not require assessing the DTRs. Ankle edema is a common finding in normal pregnancy due to increased blood volume and fluid retention.
Choice C is incorrect because assessing the DTRs during admission to labor and delivery is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs during admission to labor and delivery can help monitor the client's neurological status, but it is not a priority action.
Choice D is incorrect because assessing the DTRs within the first trimester of pregnancy is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs within the first trimester of pregnancy can help establish a baseline, but it is not a priority action.
Correct Answer is ["A","E"]
Explanation
Choice A: Consuming foods with saturated fats is not a healthy lifestyle change for a client with coronary artery disease, as this can increase the level of cholesterol and triglycerides in the blood, which can lead to plaque formation and narrowing of the arteries. Therefore, this statement indicates that the client needs additional education.
Choice B: Walking 30 minutes per day is a beneficial lifestyle change for a client with coronary artery disease, as this can improve the blood circulation, lower the blood pressure, and reduce the risk of heart attack and stroke. Therefore, this statement does not indicate that the client needs additional education.
Choice C: Using a salt substitute is a helpful lifestyle change for a client with coronary artery disease, as this can reduce the sodium intake, which can lower the blood pressure and prevent fluid retention. Therefore, this statement does not indicate that the client needs additional education.
Choice D: Keeping a food diary is a useful lifestyle change for a client with coronary artery disease, as this can help the client monitor their calorie intake, portion size, and nutritional quality of their food. This can also help the client identify and avoid unhealthy food choices. Therefore, this statement does not indicate that the client needs additional education.
Choice E: Eating more canned vegetables is not a good lifestyle change for a client with coronary artery disease, as canned vegetables often contain high amounts of sodium, which can raise the blood pressure and worsen the condition. Therefore, this statement indicates that the client needs additional education.
Choice F: Including oatmeal for breakfast is an advantageous lifestyle change for a client with coronary artery disease, as oatmeal contains soluble fiber, which can lower the cholesterol level and prevent plaque formation in the arteries. Therefore, this statement does not indicate that the client needs additional education.
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