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 D
Explanation
A. An abdominal sonogram is not used to diagnose or manage mastitis. Mastitis is typically evaluated and managed through clinical examination and does not require imaging of the abdomen.
B. Limiting fluid intake is not recommended for managing mastitis. Adequate hydration is important to support the body's healing processes and help with milk production.
C. A bra should be supportive, not loose-fitting, to help manage mastitis. A well-fitting, supportive bra can help alleviate discomfort and provide proper support during breastfeeding.
D. Continuing to breastfeed or pumping milk is encouraged to help resolve mastitis. Frequent milk removal can help clear the infection and prevent complications, such as an abscess.
Correct Answer is []
Explanation
- Potential Condition: Hyperemesis Gravidarum
Actions to take
- Insert a peripheral venous access device:
- Monitor and manage electrolyte values:
Parameters to monitor
- Electrolyte values:
- Urine ketones:
Rationale
- Potential Condition: Hyperemesis Gravidarum
- This condition is characterized by severe nausea and vomiting, leading to dehydration and nutrient loss, which can affect both the mother and fetus.
- Actions to Take:
1. Insert a peripheral venous access device:
- This will allow for the administration of IV fluids and medications to treat dehydration and correct electrolyte imbalances.
2. Monitor and manage electrolyte values:
- Given the client's low potassium levels, it's crucial to monitor and manage electrolytes to prevent complications.
- Parameters to Monitor:
1. Electrolyte values:
- Monitoring electrolyte levels is essential to ensure they are within normal ranges and to adjust IV fluid composition as needed.
2. Urine ketones:
- Positive urine ketones indicate that the body is using fat for energy due to inadequate glucose utilization, which is common in Hyperemesis Gravidarum. Monitoring will help assess the effectiveness of treatment and nutritional status.
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