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:
"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.
Choice B Reason:
"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.
Choice C Reason:
"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.
Choice D Reason:
"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.