A nurse is preparing to collect a blood specimen from a newborn via heelstick. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Place a heel warmer on the newborn's heel.
Confirm the identity of the newborn.
Apply pressure to the puncture site with a dry gauze pad.
Label the specimen per facility protocol.
Clean the puncture site with an antiseptic cleanser.
The Correct Answer is B, A, E, C, D
This sequence ensures proper identification, infection control, specimen collection, and safety for the newborn.
Choice A rationale:
The nurse should place a heel warmer on the newborn's heel for 3 to 5 minutes before the heelstick to increase blood flow and facilitate collection.
Choice B rationale:
The nurse should confirm the identity of the newborn before collecting any specimen to ensure patient safety and avoid errors.
Choice C rationale:
The nurse should apply pressure to the puncture site with a dry gauze pad to stop bleeding and promote clotting.
Choice D rationale:
The nurse should label the specimen per facility protocol to ensure accurate identification and processing.
Choice E rationale:
The nurse should clean the puncture site with an antiseptic cleanser to prevent infection and reduce contamination of the specimen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Restricting fluid intake is not the primary concern when taking lithium. It's more important to maintain a consistent level of sodium intake.
Choice B rationale:
Doubling the dose of lithium without medical supervision can lead to lithium toxicity, which can be life-threatening.
Choice C rationale:
Sodium levels can impact the effectiveness and safety of lithium. Consuming a moderate- sodium diet helps prevent sodium depletion or overload, which can affect lithium levels.
Choice D rationale:
Slurred speech is not indicative of low lithium levels. It's important to monitor for signs of lithium toxicity, which include tremors, confusion, and GI symptoms.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:
Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.
Choice C rationale:
Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).
Choice D rationale:
Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.
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