The nurse is preparing to provide an enteral feeding to a preterm infant. Which is the priority nursing action prior to administering the feeding?

A) Weigh the current diaper.
B) Measure abdominal girth.
C) Weigh the baby.
D) Measure pulse oximetry.


Answer: B

Before each feeding, the nurse should measure the abdominal girth to determine abdominal distention, which is seen in necrotizing enterocolitis or paralytic ileus. Weighing the baby and weighing diapers are interventions to assess for fluid volume status. Measuring pulse oximetry is an intervention for assessing oxygenation.

Nursing

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A 20-year-old woman has visited her family physician due to occasional bouts of bloody diarrhea over the past several weeks, a phenomenon that she experienced 2 years prior as well

Her physician has diagnosed her with ulcerative colitis based on her history and visualization of the affected region by colonoscopy and sigmoidoscopy. Which of the following pathophysiological phenomena is most likely to underlie the client's health problem? A) Fissures and crevices developing in the mucosa that are seen as a characteristic "cobblestone" appearance B) Erosion of the endothelial lining of the distal small intestine by a combination of genetic, autoimmune, and environmental factors C) Compromise of the mucosal layer of the large intestinal surface by the effects of H. pylori D) Mucosal hemorrhages that have developed into crypt abscesses, which have in turn necrotized and ulcerated

Nursing

For a client with mild benign prostatic hypertrophy (BPH) who will be treated conservatively, the nurse would advise the client to

a. avoid alcoholic beverages. b. limit fluid intake. c. limit sexual intercourse. d. void every couple of hours.

Nursing

A nursing instructor is teaching about case management. What student statement indicates that learning has occurred?

A. "Case management is a method used to achieve independent client care." B. "Case management provides coordination of services required to meet client needs." C. "Case management exists to facilitate client admission to needed inpatient services." D. "Case management is a method to facilitate physician reimbursement."

Nursing

A man says, "I just can't get myself to leave the house and go for a 30-minute walk each day. I wish I could think of some way to motivate myself." Which of the following would be the best action for the nurse to take?

a. Establish a written contract between him and his employer that states walking is required each day. b. Recognize the reasons why 30 minutes of walking each day is one of the best health promotion activities he can choose. c. Join a group that walks early each morning. d. Set up rewards for himself, such as a nice snack after he gets back from walking.

Nursing