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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"This type of device is useful for a client who cannot assist." This statement accurately reflects the purpose of a mechanical lift. Mechanical lifts are designed to assist individuals who have limited or no weight-bearing capacity, making them suitable for clients who cannot actively participate in the transfer process. These devices provide support and aid in moving the client safely and comfortably.
Choice B Reason:
"The lower end of the sling goes below the client's calves. This statement is incorrect. The lower end of the sling typically goes under the client's thighs, not below the calves. Placing the sling under the thighs provides proper support and stability during lifts and transfers.
Choice C Reason:
"The sides of the sling are for the client to hold on to." This statement is incorrect. The sides of the sling are not meant for the client to hold on to. The sling is designed to cradle and support the client's body during transfers, ensuring a secure and comfortable lift without relying on the client's strength.
Choice D Reason:
"The device requires the client to use upper body strength." This statement is incorrect. The primary purpose of a mechanical lift is to minimize the physical effort required from the client. These devices are designed to lift and transfer clients with minimal assistance from the client, reducing the risk of injury and ensuring a safe transfer for both the client and the caregiver.
Correct Answer is A
Explanation
A client can withdraw consent at any time. This statement is accurate. Informed consent is a process that involves providing the client with information about a procedure or treatment, including its risks and benefits, to enable them to make an informed decision. A client has the right to withdraw their consent at any point in the process.
Choice B Reason:
A family member should witness the client's consent. The witnessing of informed consent is typically done by a healthcare professional involved in the procedure or a neutral third party, not a family member.
Choice C Reason:
A nurse is responsible for obtaining informed consent. While nurses may assist with the informed consent process by providing information and answering questions, the ultimate responsibility for obtaining informed consent usually lies with the healthcare provider performing the procedure.
Choice D Reason:
A minor who is pregnant is unable to give consent. The ability of a minor to give consent can vary based on jurisdiction and the specific circumstances. In many cases, minors may be able to provide consent for certain medical procedures, particularly if they are deemed mature enough to understand the implications. Being pregnant might not necessarily preclude a minor from giving consent. Legal and ethical considerations regarding minors' consent can vary, and healthcare providers should be aware of local regulations and guidelines.
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