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 minutes prior to the procedure.

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

Answer and Explanation

The Correct Answer is C

The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood ﬂow to the area and makes it easier to obtain the specimen.

a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.

b) Withholding feeding prior to collecting the specimen is not necessary.

d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A nurse admitting a client who has active tuberculosis should place the client in a room that is ventilated to

the outside. This is an appropriate nursing intervention to prevent the spread of tuberculosis to others.

The other options are not correct.

b) The nurse does not need to wear a gown when delivering the client's food tray but should wear a mask and gloves.

c) Visitors are not prohibited while the client's infection is activebut should be limited and should wear masks.

d) A tuberculin skin test is not necessary prior to discharge as the client has already been diagnosed with active tuberculosis.

A. Preinteraction phase B. Working phase C. Orientation phase D. Termination phase

Correct Answer is B

Explanation

The therapeutic relationship can be described in terms of four sequential phases: preinteraction phase, introduction/orientation phase, working phase, and termination phase . In the working phase, most of the therapeutic interventional activities are carried out . This is the phase where the nurse should help the client develop problem-solving skills.

The other options are not correct because:

a) The preinteraction phase starts when the nurse is given the responsibility to start a therapeutic relationship with a patient.

c) The introduction/orientation phase is the first meeting of the nurse with her client (patient).

d) The termination phase is the final stage of the nurse-client relationship.

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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 admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?

Correct Answer is A

Explanation

A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem-solving skills?

Correct Answer is B

Explanation

A nurse is collecting data on a client who has swelling of the lower leg. The nurse should identify that which of the following findings is a manifestation of compartment syndrome?

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A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?

A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure?

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