Which is the priority nursing intervention when caring for a neonate who is born with bladder exstrophy?
1. Measuring intake and output
2. Inserting a Foley catheter
3. Covering the defect with sterile plastic wrap
4. Palpating the bladder mass to ensure urine is expelled
3
Explanation:
1. Because the bladder constantly drains onto the skin of the abdomen, measuring output is not possible.
2. The bladder is open to the abdomen. A Foley catheter cannot be inserted.
3. This reduces the contamination of the bladder, which should be sterile.
4. The bladder is very sensitive and palpation would cause unnecessary pain.
You might also like to view...
During a physical assessment, the nurse notes a patient has profuse secretions of sweat. The nurse should document that the patient is experiencing:
a. dyspnea. b. cyanosis. c. diaphoresis. d. ecchymosis.
____________________ are employees who are proficient in the use of the information system and can serve as mentors to other end-users in their department
Fill in the blank(s) with correct word
Mr. and Mrs. Close are a happily married couple in their 70s who have been together for 50 years. They present together at your clinic and seem reluctant to state their concern
In response to your observation about their uneasiness, Mr. Close tells you that they have been having difficulties with intercourse and don't know who to talk to. "Our children think it is shameful that we still have sex at our ages, so we can't talk to them." You respond: A) "I think your children have your best interest at heart." B) "What do you think about people your age being sexual?" C) "It is perfectly normal to be intimate at any age. Here are some pamphlets about sexuality in later adult years." D) "I wish more people thought as you do about sexuality!"
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include
when delegating care for this client? (Select all that apply.) a. "Do not allow the client to eat between meals." b. "Make sure the client receives a protein shake." c. "Do not allow caffeine-containing beverages." d. "Make sure the foods are bland with little spice." e. "Do not allow high-carbohydrate food items."