A laboratory technician arrives to draw blood for a complete blood count (CBC) for a client who had a right-sided mastectomy 8 hours ago. The client has an intravenous line with fluid infusing in her left antecubital space. To obtain the blood specimen, the technician places a tourniquet on the client's right arm. Which action by the nurse would be most appropriate?
Call the surgeon to perform a femoral puncture.
Assist in holding the client's arm still.
Tell the technician to obtain the blood sample from the client's left arm.
Suggest a finger stick be done on one of the client's left fingers.
The Correct Answer is C
Choice A: Call the surgeon to perform a femoral puncture. This action is not appropriate because it is unnecessary and invasive. A femoral puncture is a procedure that involves inserting a needle into the femoral vein in the groin area to obtain a blood sample. It is usually reserved for situations where other veins are inaccessible or unsuitable, such as in trauma or shock. It is not indicated for a routine CBC test.
Choice B: Assist in holding the client's arm still. This action is not appropriate because it is harmful and contraindicated. Holding the client's arm still may cause injury or infection to the arm that has undergone surgery and lymph node removal. It may also increase the risk of lymphedema, which is a condition that causes swelling and pain in the arm due to fluid accumulation and impaired lymphatic drainage.
Choice C: Tell the technician to obtain the blood sample from the client's left arm. This action is appropriate because it is safe and recommended. Obtaining the blood sample from the client's left arm can avoid complications such as injury, infection, or lymphedema in the right arm that has undergone surgery and lymph node removal. The technician can use a different site than the antecubital space, such as the hand or wrist, to avoid interfering with the intravenous line.
Choice D: Suggest a finger stick be done on one of the client's left fingers. This action is not appropriate because it is unreliable and inaccurate. A finger stick is a procedure that involves pricking the finger with a lancet to obtain a small amount of blood for testing. It is usually used for point-of-care testing, such as glucose or hemoglobin levels, but not for a CBC test. A CBC test requires a larger volume of blood and a venous sample for accurate results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A:This response suggests that a physical examination is necessary before providing contraceptive advice. While a healthcare provider may conduct a physical examination as part of comprehensive care, making it a prerequisite for discussing contraception can create barriers for adolescents seeking information. Emphasizing a physical exam may deter open communication, as adolescents might feel apprehensive or judged. Effective contraceptive counseling should prioritize building rapport and understanding the individual's needs and concerns before proceeding to clinical
Choice B: "You are so young. Are you ready for the responsibilities of a sexual relationship?" This response is inappropriate and judgmental because it implies that the client is too immature or irresponsible to have a sexual relationship. It also discourages the client from seeking help or information from the nurse and may make her feel ashamed or guilty about her sexuality.
Choice C: "Because of your age, I think that a barrier method would be the best choice." This response is inappropriate and paternalistic because it assumes that the nurse knows what is best for the client without considering her individual situation or preferences. It also limits the client's options and may not address her specific needs or concerns.
Choice D:This response is appropriate as it seeks to gather more information about the adolescent's sexual activity, which is crucial for providing tailored contraceptive advice. Understanding the individual's sexual behavior, frequency of activity, number of partners, and risk factors allows the healthcare provider to recommend the most suitable contraceptive methods and address any concerns about sexually transmitted infections. The Centers for Disease Control and Prevention highlight the importance of personalized counseling that takes into account the adolescent's specific circumstances to promote effective contraceptive use and sexual health.
Correct Answer is A
Explanation
Choice A: Encourage her to turn, cough, and deep breathe at frequent intervals. This intervention is appropriate for the nurse to include in the client's plan of care at this time because it can help prevent respiratory complications such as atelectasis (collapse of lung tissue) or pneumonia after surgery. Turning, coughing, and deep breathing can help expand the lungs, clear the airways, and improve oxygenation.
Choice B: Ask the client how she feels about having her breast removed. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it may be too intrusive or insensitive. Asking the client how she feels about having her breast removed may trigger emotional distress or anxiety in the client who has just undergone a major surgery that affects her body image and self-esteem. The nurse should wait until the client is more stable and ready to talk about her feelings and concerns.
Choice C: Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Attaching a sign above her bed to have BP, IV lines, and lab work in her right arm may cause injury or infection to the arm that has undergone surgery and lymph node removal. The nurse should attach a sign above her bed to have BP, IV lines, and lab work in her left arm instead.
Choice D: Position her right arm below heart level. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Positioning her right arm below heart level may impair the blood circulation and lymphatic drainage of the arm that has undergone surgery and lymph node removal. The nurse should position her right arm above heart level instead.
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