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 D
Explanation
Choice A: Securing chest tube to the stretcher for transport is a good practice, but it is not the most important action. The chest tube should be secured to prevent accidental dislodgement or kinking, but it does not affect the function of the chest tube or the drainage system.
Choice B: Administering PRN pain medication prior to transport is a compassionate action, but it is not the most important action. The client may experience pain due to the chest tube, the intubation, or the underlying condition, but pain relief is not a priority over maintaining adequate ventilation and drainage.
Choice C: Marking the amount of chest drainage on the container is a useful action, but it is not the most important action. The amount of chest drainage should be recorded and reported to monitor the client's status and detect any complications, such as hemorrhage or infection, but it does not affect the immediate function of the chest tube or the drainage system.
Choice D: Keeping the chest tube container below the site of insertion is the most important action for the nurse to take. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.
Correct Answer is C
Explanation
Choice C is correct because observing the incision site of a client who was discharged home with a suprapubic catheter can help detect signs of infection, bleeding, or healing problems. The nurse should inspect the incision site for redness, swelling, drainage, or odor and report any abnormal findings.
Choice A is incorrect because measuring abdominal girth of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary retention or obstruction. The nurse should monitor the urine output and color and report any changes.
Choice B is incorrect because assessing perineal area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of infection or irritation. The nurse should instruct the client on how to keep the perineal area clean and dry and report any discomfort or discharge.
Choice D is incorrect because palpating flank area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary tract infection or kidney involvement. The nurse should ask the client about any pain or tenderness in the flank area and report any positive findings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today