A nurse is caring for a client who is crying after receiving a terminal cancer diagnosis. Which of the following responses should the nurse make?

Rationale:

A. Don sterile gloves prior to the procedure: Clean gloves, not sterile gloves, are required for a capillary blood glucose test since it is a clean, not sterile, procedure. Sterile technique is unnecessary and not cost-effective for this type of routine testing.

B. Hold the finger in an upright position prior to the procedure: The finger should be held in a dependent (downward) position to promote blood flow to the puncture site. Holding it upright may reduce perfusion and make obtaining an adequate sample more difficult.

C. Use the lateral tip of the finger to obtain specimen: The lateral sides of the fingertip have fewer nerve endings than the center and are more vascular, making them ideal for obtaining an adequate blood sample with minimal discomfort to the client.

D. Discard the lancet in the trash container: Lancets are sharp instruments and must be discarded in an approved sharps container to prevent needle-stick injuries and ensure proper infection control. Disposing of them in regular trash poses a safety hazard.

Rationale:

A. Place eye covers on the newborn while under the lights: Eye protection is essential during phototherapy to prevent retinal damage from the high-intensity blue light. The covers should be properly fitted and removed only during feedings or when the therapy is paused.

B. Apply an emollient lotion to skin that is exposed to the lights: Emollients are not recommended during phototherapy because they can increase the risk of burns or interfere with light penetration. The newborn’s skin should remain clean and dry to ensure safety and effective treatment.

C. Remove all blankets, clothing and diapers while the newborn is under lights: While minimal clothing is used to expose as much skin as possible, the diaper is typically kept in place to protect the genital area and reduce the risk of contamination. Full removal is not necessary or recommended.

D. Keep the newborn as close to the light source as possible: The distance between the newborn and the phototherapy light should be within manufacturer guidelines. Moving the newborn too close can increase the risk of overheating or skin damage, so positioning must follow safety standards.