1. A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Puncture the heel and collect the blood.
Apply pressure with a dry gauze pad.
Wrap a warm, moist cloth around the heel.
Cover the heel with an adhesive bandage.
Cleanse the heel with an antiseptic.
The Correct Answer is C,E,A,B,D
1. Wrap a warm, moist cloth around the heel to dilate the blood vessels, which makes it easier to obtain the blood sample.
2. Cleanse the heel with an antiseptic to reduce the risk of infection at the puncture site.
3. Puncture the heel and collect the blood, ensuring that the sample is adequate for the test.
4. Apply pressure with a dry gauze pad to stop the bleeding from the puncture site.
5. Cover the heel with an adhesive bandage to protect the area and minimize the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- Rationale for A: Aspirin is an antiplatelet agent and can increase the risk of bleeding, especially when combined with warfarin, an anticoagulant. Therefore, taking aspirin for leg discomfort is not recommended as it can exacerbate bleeding risks.
- Rationale for B: Oral contraceptives can interfere with the effectiveness of warfarin and increase the risk of thrombotic events. Women taking warfarin, especially in the postpartum period, should avoid oral contraceptives due to the potential for increased blood clotting.
- Rationale for C: The duration of warfarin therapy for deep-vein thrombosis is typically longer than 2 weeks. It is determined by the physician based on the extent of the clot and the patient's response to the medication.
- Rationale for D: Using a disposable razor can help minimize the risk of cuts and subsequent bleeding, which is a concern when taking anticoagulants like warfarin. It is a safer alternative to other shaving methods that may cause skin abrasions.
Correct Answer is C
Explanation
A. Experiencing burning during urination is not a normal physiological change during pregnancy and could indicate a urinary tract infection. It is important to report this symptom to a healthcare provider for evaluation and appropriate management.
B. The dark line in the middle of the abdomen, known as the linea nigra, is a common and normal physiological change during pregnancy due to hormonal effects, not an indication of infection. This statement reflects a misunderstanding of normal pregnancy changes.
C. Developing discoloration on the cheeks, often referred to as the "mask of pregnancy" or melasma, is a common and expected physiological change due to hormonal fluctuations. This statement shows that the client understands a normal aspect of pregnancy.
D. Swelling of the fingers and face is not a typical or expected change during pregnancy and could indicate a serious condition such as preeclampsia. While mild swelling of the ankles and feet can be normal, swelling in these areas should be evaluated by a healthcare provider.
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