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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Taking the newborn back to the nursery is incorrect. While rest is important for the mother, removing the baby does not help build her confidence or teach her how to respond to her infant’s needs. Supporting her in learning newborn care is more beneficial.

B. Turning the baby on his side to help him sleep is incorrect. The safest sleep position for a newborn is on the back, according to safe sleep guidelines. Additionally, this response does not address the mother's feelings of inadequacy.

C. Explaining that babies cry to develop their lungs is incorrect. While crying is normal for newborns, this response dismisses the client’s concern rather than providing reassurance and support.

D. Showing the mother how to swaddle and cuddle the baby, then letting her try is correct. This approach provides practical guidance and empowers the mother, helping her build confidence in her ability to care for her newborn.

A. Check the client's vital signs every 4 hr. B. Provide the client with high-calorie finger foods. C. Encourage the client to participate in group activities. D. Allow the client to establish his own schedule.

Correct Answer is B

Explanation

A. Check the client's vital signs every 4 hr.: Although monitoring vital signs is important, it is not the primary concern in acute mania unless the client is showing signs of physical distress (e.g., tachycardia, dehydration).

B. Provide the client with high-calorie finger foods.: This is correct. During acute mania, clients may have difficulty sitting down to eat, and high-calorie finger foods can help ensure the client gets adequate nutrition. These foods are easy to consume and provide the necessary calories.

C. Encourage the client to participate in group activities.: While socialization can be beneficial, group activities may overstimulate a client in acute mania and could lead to further agitation. It is better to encourage more structured and individual activities initially.

D. Allow the client to establish his own schedule.: Clients in acute mania may have poor judgment and impulsive behavior. Allowing them to establish their own schedule could lead to disorganized behavior. The nurse should offer structure to prevent this.

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A nurse is obtaining a capillary blood specimen to measure a client's blood glucose. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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