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 C
Explanation
Choice A: Assessing pupillary response to light hourly is not related to dopamine administration. Dopamine does not affect the pupils or the cranial nerves that control them.
Choice B: Initiating seizure precautions is not necessary for a client receiving dopamine. Dopamine does not lower the seizure threshold or cause convulsions.
Choice C: Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine increases blood pressure and cardiac output, which improves renal perfusion and urine production. Urinary output is an indicator of the effectiveness of dopamine therapy and renal function.
Choice D: Monitoring serum potassium frequently is not directly related to dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia. However, potassium levels may be affected by other factors such as fluid balance, renal function, and medications.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: This is incorrect because instructing the client and family to reconsider end of life choices is disrespectful and insensitive. The nurse should respect the client's autonomy and preferences and support their decisions.
Choice B reason: This is correct because teaching the client how to use guided imagery is a helpful intervention for coping with feelings related to death and dying. Guided imagery is a relaxation technique that involves visualizing positive images and scenarios that can reduce stress, anxiety, and pain.
Choice C reason: This is correct because recording the client's desire to live is an important intervention for coping with feelings related to death and dying. The nurse should acknowledge and validate the client's emotions and help them express their hopes and fears.
Choice D reason: This is correct because encouraging family to visit frequently is a beneficial intervention for coping with feelings related to death and dying. The nurse should facilitate family involvement and communication and help the client maintain meaningful relationships.
Choice E reason: This is correct because encouraging family to bring the client old photographs is a useful intervention for coping with feelings related to death and dying. The nurse should assist the client in reminiscing and reviewing their life story and achievements.
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