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: Inspecting feet every month for ingrown nails, cuts, and calluses is not a statement that indicates understanding, as this is not frequent enough for a client with diabetes who may have impaired sensation and circulation in their feet. The recommended frequency is daily or at least weekly. This is an incorrect choice.
Choice B: Arranging diet schedule around three regular meals a day is not a statement that indicates understanding, as this may not be adequate for a client with diabetes who needs to balance their carbohydrate intake and blood glucose levels throughout the day. The recommended schedule is to have smaller and more frequent meals and snacks. This is another incorrect choice.
Choice C: Getting an eye examination with an ophthalmologist annually is a statement that indicates understanding, as this can help detect and prevent diabetic retinopathy, which can cause vision loss and blindness. Therefore, this is the correct choice.
Choice D: Using salt, herbs, and spices will improve the flavor of foods is not a statement that indicates understanding, as this may not be healthy for a client with diabetes who needs to limit their sodium intake and avoid potential interactions between herbs and medications. The recommended strategy is to use low-sodium seasonings and natural flavors. This is another incorrect choice.
Correct Answer is A
Explanation
Choice B reason: Blood pressure of 122/74 mm Hg is within the normal range for a postpartum client and does not indicate an infection. However, the nurse should monitor for signs of preeclampsia or eclampsia, such as hypertension, proteinuria, headache, blurred vision, and seizures.
Choice C reason: Oral temperature of 100.2°F (37.9°C. is slightly elevated, but not necessarily indicative of an infection. A mild fever may occur within the first 24 hours after delivery due to dehydration or hormonal changes. However, if the fever persists or increases, the nurse should suspect an infection and notify the healthcare provider.
Choice D reason: White blood cell count of 19,000/mm^3 (19 x 10^9/L) is higher than the normal range, but not necessarily indicative of an infection. A leukocytosis or increased WBC count may occur as a normal response to stress or trauma during delivery. However, if the WBC count remains elevated or increases further, the nurse should suspect an infection and notify the healthcare provider.
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