A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

Puncture the heel to a depth of 4 mm to obtain the specimen.

Withhold feeding prior to collecting the specimen.

Apply a heat pack 5 to 10 min prior to the procedure.

Elevate the newborn's foot for 15 min following the procedure.

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Puncturing the heel to a depth of 4 mm may be too deep and could cause injury to the newborn's foot. The recommended depth is usually less than 2 mm to avoid damaging underlying bone or tissues.
Choice B Rationale: Withholding feeding prior to collecting the specimen is not necessary and could cause unnecessary distress to the newborn. Feeding can help in soothing the infant and may even improve blood flow for the procedure.
Choice C Rationale: Applying a heat pack 5 to 10 minutes prior to the procedure is recommended as it helps to increase blood flow to the area, making the collection easier and potentially less painful for the newborn.
Choice D Rationale: Elevating the newborn's foot for 15 minutes following the procedure is not a standard recommendation. Post-procedure care typically involves applying gentle pressure to stop bleeding and then covering the puncture site with a bandage.

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Correct Answer is A

Explanation

A. Using an adhesive remover can help safely and effectively remove the adhesive residue from the skin without causing irritation or damage.
B. Scrubbing the skin around the colostomy can cause skin irritation and increase the risk of skin breakdown. Gentle cleaning with warm water and mild soap is recommended.
C. Most colostomy bags do not require suctioning of stool, as they are designed to collect fecal matter without the need for suctioning.
D. It is generally recommended to empty the colostomy bag when it is about one-third to one- half full to prevent leakage and maintain skin integrity.

A. Elevated WBC count B. increased temperature C. Nausea and vomiting D. Abdominal pain E. Muscle guarding

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,C"}}

Explanation

Assessment finding	Appendicitis	Celiac disease	Diverticulitis
Elevated WBC count	✔		✔
increased temperature	✔		✔
Nausea and vomiting	✔	✔	✔
Abdominal pain	✔	✔	✔
Muscle guarding	✔		✔

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A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse in the emergency department is assisting with the care of a client. Exhibits For each assessment finding below, click to specify if the finding is consistent with appendicitis, diverticulitis, or celiac disease. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,C"}}

Explanation

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