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:
"He may need a feeding tube" is inappropriate response. Suggesting a feeding tube without further assessment or information might be premature and could cause unnecessary concern or anxiety for the son. It's essential to explore the situation more before proposing such an intervention.

Choice B Reason:
"Tell me more about what happens at mealtime” is appropriate response. This response encourages the son to provide further details about the situation, allowing the nurse to gather more information about the specific issues or challenges related to the client's eating habits. Understanding the circumstances around mealtime can help the nurse identify potential reasons for the lack of appetite or eating difficulties and offer more targeted guidance or solutions.

Choice C Reason:
"Why do you think he's not eating?" This response is inappropriate. While asking about the son's thoughts is valuable, this question might not directly address the situation at hand or provide immediate assistance or guidance to address the client's eating difficulties.

Choice D Reason:
"I'm sure it's nothing serious and his appetite will return soon” is inappropriate response. Offering reassurance without understanding the underlying cause may downplay a potentially concerning issue. It's crucial to investigate the reasons behind the lack of appetite before assuming it will resolve without further action.

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

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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