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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Insert the suppository 5 cm (2 in) is incorrect. The suppository should be inserted about 2-3 inches into the vaginal canal, not specifically 5 cm, but the exact depth may vary.
B. Insert the suppository along the posterior vaginal wall is correct. Inserting the suppository along the posterior vaginal wall helps ensure it reaches the area where it is needed for effective treatment.
C. Apply petroleum jelly to the suppository is incorrect. The suppository should not be coated with petroleum jelly; it should be used as is to avoid interference with its absorption and effectiveness.
D. Assist the client into a prone position is incorrect. The client should be assisted into a supine position with knees bent or into a lithotomy position for the insertion of the suppository, not a prone position.

A. Nausea B. Crackles C. Dizziness D. Tremors

Correct Answer is B

Explanation

A. Nausea is a common side effect of terbutaline but does not typically require urgent reporting. It can be managed with supportive care or adjustments in therapy.
B. Crackles in the lungs are a serious side effect of terbutaline, which can cause pulmonary edema due to fluid retention. This finding indicates a potential adverse reaction that must be reported to the provider for further evaluation and management.
C. Dizziness can occur with terbutaline use but is not as immediately concerning as other potential side effects. It may be managed by adjusting the dose or monitoring the client.
D. Tremors are a common and less severe side effect of terbutaline, typically caused by its beta-adrenergic effects. While they are uncomfortable, they are not an immediate concern compared to more severe reactions.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

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