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 reason: Observing the insertion site of the suprapubic catheter is an essential assessment for the home health nurse, as this can help detect any signs of infection, inflammation, or leakage. Therefore, this is the correct choice.
Choice B reason: Palpating the flank area is not a necessary assessment for the home health nurse, as this is not related to the suprapubic catheter. This is a distractor choice.
Choice C reason: Measuring abdominal girth is not a relevant assessment for the home health nurse, as this is not affected by the suprapubic catheter. This is another distractor choice.
Choice D reason: Assessing the perineal area is not an important assessment for the home health nurse, as this is not involved in the suprapubic catheter. This is another distractor choice.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C reason: vitamin K can interfere with the anticoagulant effect of warfarin and increase the risk of clotting. The client should maintain a consistent intake of vitamin K from food sources, such as dark green leafy vegetables, to avoid fluctuations in the blood levels of warfarin.
Choice A reason: increasing the intake of dark green leafy vegetables while taking warfarin can decrease the effectiveness of warfarin and increase the risk of clotting.
Choice B reason: eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed can cause unpredictable changes in the blood levels of warfarin and increase the risk of bleeding or clotting.
Choice D reason: avoiding any foods that contain any vitamin K while taking warfarin can increase the sensitivity to warfarin and increase the risk of bleeding.
Correct Answer is B
Explanation
Choice A reason: Assigning the UAP to provide care for another client and assume full care of the client is not an action that the nurse should take, as this is unnecessary and inefficient. The UAP can safely assist the client with influenza if they follow proper infection control measures. This is an incorrect choice.
Choice B reason: Reviewing the need for the UAP to wear a face mask while in close contact with the client is an action that the nurse should take, as this can protect the UAP and others from droplet transmission of influenza. This is a standard precaution that should be reinforced by the nurse. Therefore, this is the correct choice.
Choice C reason: Instructing the UAP to apply a fitted respirator mask before entering the client's room is not an action that the nurse should take, as this is not indicated for a client with influenza. A respirator mask is required for airborne transmission, not droplet transmission. This is another incorrect choice.
Choice D reason: Directing the UAP to notify the nurse of any changes in the client's respiratory status is not an action that the nurse should take, as this is a general instruction that does not address the specific issue of infection control. This is another incorrect choice.
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