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 B

Explanation

Choice A Reason:

Inflating the catheter's balloon is done after proper placement to secure the catheter in the bladder. It should not be done when there is resistance and no urine flow.

Choice B Reason:

Twisting the catheter gently is correct. Resistance during catheter insertion may indicate the catheter is encountering an obstruction or is misaligned. Gently twisting the catheter can help navigate around obstructions or correct misalignment without causing trauma to the urethra.

Choice C Reason:

Applying lidocaine gel to the urethra is typically used for lubrication and to numb the urethra during catheter insertion, but it may not address the issue of resistance or lack of urine flow.

Choice D Reason:

Lowering the penis to a 45° angle is not a standard action in response to resistance during catheter insertion. Twisting the catheter gently is a more appropriate initial step.

A. Keep her arms at the sides of her body with her hands in a relaxed position. B. Interlock her fingers and hold her hands away from her body above her waist. C. Clasp her hands together in a relaxed position behind her body at her waist. D. Place one hand over the other against the part of the gown covering her upper body.

Correct Answer is B

Explanation

Choice A Reason:

Keep her arms at the sides of her body with her hands in a relaxed position is wrong. Keeping the hands in a relaxed position at the sides of the body may increase the risk of accidental contact with non-sterile surfaces.

Choice B Reason:

Interlock her fingers and hold her hands away from her body above her waist is wright. Interlocking fingers and holding hands above the waist may increase the risk of accidental contact with non-sterile surfaces.

Choice C Reason:

Clasp her hands together in a relaxed position behind her body at her waist is wrong. This positioning helps maintain sterility by keeping the hands away from potential contaminants and below the waist level. Placing the hands behind the body avoids accidental contact with non-sterile surfaces or objects.

Choice D Reason:

Place one hand over the other against the part of the gown covering her upper body is wrong. Placing hands on the gown covering the upper body may lead to contamination, as the gown is considered non-sterile on the outside. The hands should be kept in a position that minimizes the risk of contact with non-sterile surfaces.

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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?

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