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: "If your sexual partner has no symptoms, no medication is needed." This statement is false and misleading. Chlamydia is a sexually transmitted infection (STI) that can cause serious complications such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain if left untreated. Chlamydia can also be passed on to newborns during delivery, causing eye infections or pneumonia. Therefore, it is important that both the client and their sexual partner(s) receive treatment and abstain from sexual activity until they are cured.
Choice B: "This infection is treated with one dose of azithromycin." This statement is true and accurate. Azithromycin is an antibiotic that can effectively treat chlamydia with one oral dose. However, some people may experience side effects such as nausea, vomiting, diarrhea, or abdominal pain after taking azithromycin. Therefore, it is important that the client follows the instructions and completes the treatment as prescribed.
Choice C: "You need to return in 6 months for retesting." This statement is false and unnecessary. Retesting for chlamydia is recommended only if the client has symptoms, has a new or multiple sexual partner(s), or is pregnant. Otherwise, retesting is not required if the client and their partner(s) have completed the treatment and have no further exposure to chlamydia.
Choice D: "You have to avoid sexual relations for 3 days." This statement is false and insufficient. The client should avoid sexual relations until they and their partner(s) have completed the treatment and have no symptoms of chlamydia. This may take longer than 3 days, depending on the type and duration of the treatment. Therefore, it is advisable that the client uses condoms or abstains from sexual activity until they are cured.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A: Rectal incontinence is not the correct answer because it is not a disorder related to pelvic organ prolapse. Rectal incontinence is a condition that causes loss of control over bowel movements, resulting in leakage of stool or gas. It can be caused by various factors, such as nerve damage, muscle weakness, or diarrhea.
Choice B: Rectocele is the correct answer because it is a disorder related to pelvic organ prolapse. Rectocele is a condition that occurs when the rectum bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue. It can cause symptoms such as constipation, difficulty emptying the bowel, or a feeling of pressure or fullness in the vagina.
Choice C: Urinary incontinence is the correct answer because it is a disorder related to pelvic organ prolapse. Urinary incontinence is a condition that causes loss of control over urination, resulting in leakage of urine or urgency to urinate. It can be caused by various factors, such as stress, urge, overflow, or mixed types of incontinence.
Choice D: Cystocele is the correct answer because it is a disorder related to pelvic organ prolapse. Cystocele is a condition that occurs when the bladder bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue. It can cause symptoms such as frequent urination, difficulty emptying the bladder, or a feeling of pressure or fullness in the vagina.
Choice E: Enterocele is the correct answer because it is a disorder related to pelvic organ prolapse. Enterocele is a condition that occurs when the small intestine bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue. It can cause symptoms such as lower back pain, pelvic pressure, or difficulty having bowel movements.
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