Which statement should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?
Measure urine output daily.
Observe urine color and clarity.
Inspect genital area for signs of infection.
Palpate flank area for tenderness.
The Correct Answer is C
Choice A: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.
Choice B: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.
Choice C: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.
Choice D: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: An adolescent with multiple contusions due to a fall that occurred 2 days ago is not a client that the charge nurse should assign to the RN, as this is a stable and low-acuity client who can be safely cared for by the PN. This is a distractor choice.
Choice B: A 75-year-old client with renal calculi who requires urine straining is not a client that the charge nurse should assign to the RN, as this is a routine and non-complex task that can be performed by the PN. This is another distractor choice.
Choice C: A 30-year-old depressed client who admits to suicide ideation is a client that the charge nurse should assign to the RN, as this is an unstable and high-risk client who requires close monitoring, assessment, and intervention by the RN. Therefore, this is the correct choice.
Choice D: A 64-year-old client who had a total hip replacement the previous day is not a client that the charge nurse should assign to the RN, as this is a postoperative and moderate-acuity client who can be managed by the PN under the supervision of the RN. This is another distractor choice.
Correct Answer is D
Explanation
Choice A: Advising the client to place one nitroglycerin tablet under his tongue as a precaution is a dangerous action for the nurse, as this can cause severe hypotension and cardiovascular collapse due to the interaction between tadalafil and nitroglycerin. This is a contraindicated choice.
Choice B: Telling the client to have someone bring him to an emergency department immediately is an unnecessary action for the nurse, as there is no evidence of any serious adverse reaction or complication from tadalafil. This is an overreaction choice.
Choice C: Instructing the client to increase his intake of oral fluids until the skin flushing is relieved is not an appropriate action for the nurse, as this does not address the cause of the flushing, which is vasodilation due to tadalafil. This is a distractor choice.
Choice D: Reassuring the client that skin flushing is a common side effect of the medication is an appropriate action for the nurse, as this can calm the client and educate him about the expected effects of tadalafil. Therefore, this is the correct choice.
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