The physician orders the Foley catheter discontinued. What nursing interventions and
teaching will you include for T.M. and his family as you implement this order?.
What will be an ideal response?
• An explanation of how the Foley catheter will be removed.
• Documentation of Foley output and proper disposal of equipment.
• Continued monitoring and measuring of urinary output. Reinforce to T.M.'s family that diapers
should be kept for documentation of weight.
• Techniques for diapering to promote skin integrity (contain stool and urine) and prevent
contamination to the spica cast.
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Four hours after the delivery of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?
a. Start an intravenous line with D5W b. Notify the clinician stat c. Document the event in the nurses' notes d. Test for blood glucose level
You are working in a prenatal clinic, performing risk assessment for postpartum depression. Which factors would increase a patient's risk for postpartum depression? Select all that apply
1) Low self-esteem 2) Multiple pregnancies 3) Unwanted pregnancy 4) Father depressed 5) History of mood disorders
Which does the nurse implement for nasotracheal suctioning?
1. Inserts the catheter about 16 cm 2. Aims catheter up through mouth 3. Prepares clean gloves and supplies 4. Applies pressure for nasal insertion
The faith community nurse who encourages participation in political activities which impact the health and well-being of the faith community is functioning as a(n):
a. Counselor b. Facilitator c. Liaison d. Advocate