A nurse is collecting a capillary blood sample from an older adult client. After puncturing the client's finger, the nurse is unable to obtain an adequate amount of blood. Which of the following actions should the nurse take?

Rub the puncture site with an alcohol pad.

Apply firm pressure to the puncture site.

Wrap the client's hand in a warm washcloth.

Have the client raise his hand.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.

Choice B Reason:

Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.

Choice C Reason:

Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.

Choice D Reason:

Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.

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Correct Answer is A

Explanation

Choice A Reason:

Placing the drainage system below the client's chest level is appropriate. This positioning allows for proper drainage and prevents the backflow of fluid or air into the chest. Maintaining the drainage system below the chest level helps ensure effective evacuation of air or fluid from the pleural space.

Choice B Reason:

Looping excess tubing next to the client's side is inappropriate. Looping excess tubing can create dependent loops, potentially causing fluid to accumulate in these areas and compromising the drainage system's effectiveness.

Choice C Reason:

Clamping the tubing when ambulating the client is inappropriate. Chest tube drainage systems should not be routinely clamped during ambulation. Clamping can lead to increased pleural pressure, potentially causing tension pneumothorax or other complications.

Choice D Reason:

Milking the client's tubing every shift is inappropriate. Milking or stripping the tubing is not recommended, as it can create a pressure gradient that may damage the lung tissue or disrupt the chest tube's seal. Passive drainage is preferred to maintain the negative pressure in the system.

A. Inflate the catheter's balloon. B. Twist the catheter gently. C. Apply lidocaine gel to the urethra. D. Lower the penis to a 45° angle.

Correct Answer is B

Explanation

Choice A Reason:

Inflating the catheter's balloon is inappropriate. Inflating the balloon at this point is not recommended. The balloon should only be inflated once the catheter is in the bladder and urine starts to flow.

Choice B Reason:

Twisting the catheter gently is appropriate. Twisting the catheter gently may help navigate any obstruction or resistance within the urethra. However, it is crucial to be cautious and not force the catheter. If resistance persists or if the catheter cannot be advanced further, the nurse should reassess the situation and consider alternative actions, such as selecting a smaller catheter or seeking assistance from a more experienced healthcare provider.

Choice C Reason:

Applying lidocaine gel to the urethra is inappropriate. Applying lidocaine gel may be appropriate for lubrication and to minimize discomfort during catheter insertion, but it will not address the issue of resistance or lack of urine flow.

Choice D Reason:

Lowering the penis to a 45° angle is inappropriate. Adjusting the angle of the penis is not likely to resolve the issue of resistance. Twisting the catheter gently or reassessing the situation would be more appropriate.

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A nurse is collecting a capillary blood sample from an older adult client. After puncturing the client's finger, the nurse is unable to obtain an adequate amount of blood. Which of the following actions should the nurse take?

Nursing Test Bank

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