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","B","C"]

Explanation

The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and

c. Check the drainage tubing for obstructions.

a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.

b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.

c. Checking the drainage tubing for obstructions is essential to ensure proper ﬂow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can aﬀect the eﬀectiveness of the procedure and potentially lead to complications.

d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.

e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.

By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.

A. "Close your mouth around the mouthpiece." B. "Exhale immediately after inhaling." C. "Tilt your head forward while inhaling." D. "Take three quick breaths while depressing the canister."

Correct Answer is A

Explanation

The correct technique for using an albuterol MDI involves closing the mouth around the mouthpiece to create a seal. This helps ensure that the medication is delivered directly into the lungs and maximizes its effectiveness. It also helps prevent the medication from escaping and being wasted.

"Exhale immediately after inhaling": This instruction is not accurate. After closing the mouth around the mouthpiece and activating the inhaler to release the medication, the client should inhale slowly and deeply through the mouth, holding their breath for about 10 seconds if possible. Exhaling immediately after inhaling would not allow enough time for the medication to be absorbed effectively.

"Tilt your head forward while inhaling": Tilted head position is not necessary when using an albuterol MDI. The client should hold the inhaler in an upright position, with the mouthpiece directed toward their mouth. This allows for proper delivery of the medication.

"Take three quick breaths while depressing the canister": This instruction is not accurate for using an albuterol MDI. The correct technique involves taking a slow and deep breath in through the mouth, while simultaneously depressing the canister to release the medication. Taking three quick breaths may not allow enough time for adequate medication delivery.

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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

A nurse is caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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