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 D

Explanation

d. Corn tortillas with black beans.

Explanation:

Celiac disease is an autoimmune disorder that requires strict adherence to a gluten-free diet. Gluten is a protein found in wheat, barley, and rye. Therefore, options a, b, and c should be avoided as they contain wheat or barley.

Option d, corn tortillas with black beans, is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.

A. Use written signs to assist the client with locating the bathroom. B. Limit the number of choices for the client. C. Provide a stimulating environment for the client. D. Use confrontation to manage the client's behavior.

Correct Answer is ["B"]

Explanation

Answer: B

Rationale:

A) Use written signs to assist the client with locating the bathroom: While written signs may be helpful in the earlier stages of Alzheimer's disease, as the disease progresses, clients may lose the ability to read and comprehend written language. Visual cues, such as pictures or color-coded indicators, tend to be more effective in helping clients navigate their environment.

B) Limit the number of choices for the client: Limiting choices reduces confusion and anxiety for clients with Alzheimer's disease. Providing too many options can overwhelm them, making decision-making difficult. Offering simple, clear choices helps to maintain a sense of autonomy while minimizing stress.

C) Provide a stimulating environment for the client: Although some stimulation can be beneficial, excessive stimulation can overwhelm a client with Alzheimer's disease, leading to agitation and confusion. It's important to create a calm, structured environment that promotes safety and reduces anxiety.

D) Use confrontation to manage the client’s behavior: Confrontation should be avoided when managing the behavior of clients with Alzheimer's disease. Confronting or challenging them can increase agitation and lead to further confusion. Instead, caregivers should use distraction, redirection, and a calm approach to manage difficult behaviors effectively.

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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?

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Naxlex Comprehensive Predictor Exams

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