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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Correct Answer is A

Explanation

Answer: A. Pull the auricle upward and outward.

Rationale:

A. Pull the auricle upward and outward:
Pulling the auricle upward and outward is the recommended technique for instilling ear drops in an adult. This method straightens the ear canal, allowing better access for the medication to reach the target area. It is essential for effective delivery and absorption of the otic suspension.

B. Pull the auricle downward and backward:
Pulling the auricle downward and backward is appropriate for children under three years old, as it aligns their shorter and straighter ear canal. In adults, this approach would not straighten the canal sufficiently for optimal medication instillation.

C. Pull the auricle upward and backward:
While pulling the auricle upward and backward can straighten the adult ear canal, the optimal direction to ensure the ear canal is fully open is upward and outward. This position allows the medication to reach deeper parts of the ear canal effectively.

D. Pull the auricle downward and outward:
Pulling the auricle downward and outward is not suitable for adults and does not provide the correct alignment for an adult ear canal. This technique is ineffective in reaching the canal's deeper parts in adult clients, thus limiting the efficacy of the medication.

A. Many people have colostomies, and they live full lives B. "Would it help to speak to someone else who has a colostomy? C. Why don't you want people to see the colostomy bag? D. The colostomy is probably only temporary

Correct Answer is A

Explanation

a. "Many people have colostomies and they live full lives."

Explanation:

The correct answer is a. "Many people have colostomies and they live full lives."

When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and oﬀers hope to the client.

Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.

Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.

Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.

By responding with the statement that many people live full lives with colostomies, the nurse oﬀers support, normalizes the client's experience, and promotes a positive outlook for the client's future.

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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

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Explanation

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Correct Answer is A

Explanation

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