the best blood collection location for a newborn is
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Nursing Elites

NCLEX-RN

NCLEX RN Predictor Exam

1. What is the BEST blood collection location for a newborn?

Correct answer: the heel

Rationale: When collecting blood from newborns, it is safest and most commonly done by collecting blood from the lateral or medial aspect of the baby's heel. This location is preferred due to the accessibility of the veins and the minimal discomfort caused to the newborn. Veins in the forehead are not commonly used for blood collection in newborns. The fingertips are not optimal for blood collection in newborns due to their small size and the potential for causing discomfort. The AC (antecubital) area, typically used in adults for blood collection, is not recommended for newborns due to the size of their veins and the potential risk of injury.

2. When a patient is standing in anatomical position, where are their feet?

Correct answer: Facing out to the sides to open the hips

Rationale: When a person is standing in anatomical position, their feet are side by side, and they are facing forward with the toes pointing out to the sides to open the hips. This position allows for proper alignment of the body for anatomical reference. Choice A is incorrect because the feet should not be spread open, but rather side by side. Choice C is incorrect as it does not mention the correct positioning of the feet. Choice D is incorrect as the feet should not be pointed inward, but rather facing out to the sides to open the hips.

3. What is the proper personal protective equipment necessary for collecting a sputum specimen?

Correct answer: Gloves and face mask

Rationale: When collecting a sputum specimen, it is crucial to protect against potential airborne droplets that may spread disease. The best personal protective equipment for this task includes gloves and a face mask. Gloves help prevent the spread of contaminants through hand contact, while a face mask protects the respiratory tract from inhaling infectious agents. Choice B, Level Three Biocontainment uniforms, is excessive and unnecessary for routine sputum specimen collection. Choice C, eye protection and shoe covers, does not address the specific risks associated with sputum collection. Choice D, splash shield and face mask, provides additional protection that is not typically required for sputum specimen collection, making it less appropriate than gloves and a face mask.

4. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?

Correct answer: “What cultural or spiritual beliefs are important to you?”

Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication. Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is “What cultural or spiritual beliefs are important to you?” This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.

5. A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?

Correct answer: The client lies on his side with the upper leg flexed

Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.

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