A nurse is obtaining a capillary blood specimen to measure a client's blood glucose. Which of the following actions should the nurse take?
Allow the antiseptic to dry before puncturing.
Apply sterile gloves.
Hold the lancet at a 45° angle.
Massage the client's finger away from the puncture site.
The Correct Answer is A
A. Allow the antiseptic to dry before puncturing.: This is correct. It is important to allow the antiseptic (such as alcohol) to dry before puncturing the skin. If the antiseptic is not allowed to dry, it can cause hemolysis of the blood sample and lead to inaccurate glucose readings.
B. Apply sterile gloves.: This is incorrect. While gloves should be worn to maintain hygiene and safety, non-sterile gloves are sufficient for a capillary blood glucose test. Sterile gloves are not necessary unless the procedure requires aseptic technique.
C. Hold the lancet at a 45° angle.: This is incorrect. The lancet should be held at a 90° angle to the skin to ensure a proper and clean puncture.
D. Massage the client's finger away from the puncture site.: This is incorrect. The finger should not be massaged before or after the puncture site because it can cause tissue damage and lead to inaccurate blood samples due to the mixing of interstitial fluid with the blood sample.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased appetite: Radiation therapy, particularly to the head and neck, can cause nausea, mouth sores, and changes in taste, leading to a decrease in appetite rather than an increase.
B. Loose stools: Loose stools are not a typical side effect of external radiation for throat cancer. Radiation can affect gastrointestinal function if the abdomen or pelvis is irradiated, but it is not commonly associated with the throat area.
C. Bladder infection: Bladder infections are more likely to be associated with treatments like chemotherapy or radiation to the pelvic region, rather than radiation to the throat.
D. Loss of taste: Radiation therapy to the head and neck, including the throat, often affects the taste buds, leading to a condition called dysgeusia, or loss of taste. This is a well-known side effect of radiation in this area.
Correct Answer is B
Explanation
A. Applying suction only during catheter removal is correct because continuous suction while inserting the catheter can cause tissue trauma and hypoxia. Intermittent suctioning during withdrawal prevents damage to the tracheal mucosa.
B. Suctioning for 30 seconds exceeds the recommended time limit, which is typically 10–15 seconds per pass for adults. Prolonged suctioning can cause hypoxia, bradycardia, and tissue trauma, making it unsafe for the client.
C. Preoxygenating with 100% oxygen before suctioning helps prevent hypoxia during the procedure. This is a standard safety measure to maintain adequate oxygen saturation levels.
D. Auscultating breath sounds before and after suctioning allows assessment of airway clearance and lung status. This step ensures that secretions have been effectively removed and helps identify any complications early.
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