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 B
Explanation
Choice A: Upper back pain is not the correct answer because it is not a common finding associated with uterine fibroids. Upper back pain is a feeling of discomfort or ache in the upper part of the back, between the shoulder blades, or below the neck. It can be caused by various factors such as muscle strain, poor posture, or spinal problems. It is not related to the presence or growth of benign tumors in the uterus.
Choice B: Chronic pelvic pain is the correct answer because it is a common finding associated with uterine fibroids. Chronic pelvic pain is a feeling of discomfort or ache in the lower abdomen or pelvis that lasts for more than six months. It can be caused by various factors such as endometriosis, ovarian cysts, or infection. It is also related to the presence or growth of benign tumors in the uterus, which can press on nerves, blood vessels, or organs and cause inflammation, bleeding, or scarring.
Choice C: Amenorrhea is not the correct answer because it is not a common finding associated with uterine fibroids. Amenorrhea is a condition that causes the absence of menstrual periods for more than three months in a woman who is not pregnant, breastfeeding, or menopausal. It can be caused by various factors such as hormonal imbalance, stress, or weight loss. It is not related to the presence or growth of benign tumors in the uterus, which can cause heavy or irregular menstrual bleeding instead.
Choice D: Diarrhea is not the correct answer because it is not a common finding associated with uterine fibroids. Diarrhea is a condition that causes loose, watery, or frequent stools. It can be caused by various factors such as infection, medication, or food intolerance. It is not related to the presence or growth of benign tumors in the uterus, which can cause constipation or bloating instead.
Correct Answer is A
Explanation
Choice A: "Information about a client can be disclosed to family members at any time." This statement indicates a need for further teaching because it is false and violates HIPAA. HIPAA protects the privacy and security of clients' health information and limits who can access or share it without their consent. Information about a client can only be disclosed to family members if they are involved in the client's care or payment, or if the client gives permission.
Choice B: "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." This statement does not indicate a need for further teaching because it is true and reflects HIPAA. HIPAA defines individually identifiable health information as any information that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.
Choice C: "HIPAA is a federal law, not a state law." This statement does not indicate a need for further teaching because it is true and reflects HIPAA. HIPAA is a federal law that was enacted in 1996 by Congress and signed by President Clinton. It applies to all states and territories of the United States. However, some states may have additional or stricter laws that protect clients' health information.
Choice D: "A client's address would be an example of personally identifiable information." This statement does not indicate a need for further teaching because it is true and reflects HIPAA. HIPAA lists 18 identifiers that can be used to identify an individual, such as name, address, phone number, email address, social security number, medical record number, or biometric identifiers. A client's address is one of these identifiers and must be protected under HIPAA.
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