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 B

Explanation

A. Encourage the client to soak in a hot bath.: While a warm bath can help alleviate muscle tension and discomfort, it is not recommended during the latent phase of labor due to the potential for increasing the risk of infection, especially if the membranes are ruptured.

B. Instruct the client to change positions frequently.: Frequent position changes during the latent stage of labor can help alleviate pelvic pain, improve comfort, and encourage progress in labor. This is a beneficial intervention that promotes movement and comfort without introducing unnecessary risks.

C. Apply fundal pressure during contractions.: Fundal pressure is not appropriate during the latent stage of labor, as it can cause fetal distress or other complications. It is typically avoided unless indicated in more advanced stages of labor under specific circumstances.

D. Tell the client to push during contractions.: Pushing is not recommended during the latent stage of labor. The latent phase involves the cervix gradually dilating, and pushing should be delayed until the active stage of labor when the cervix is fully dilated and ready for delivery.

A. Inspect the preschooler's tonsils for edema. B. Collect a sputum sample. C. Determine the preschooler's oxygen saturation level. D. Obtain a specimen for throat culture.

Correct Answer is C

Explanation

A. Inspect the preschooler's tonsils for edema.: While tonsil inspection might be part of a general assessment, in a child with suspected epiglottitis, inspecting the throat should be avoided as it can trigger airway obstruction or cause further distress.

B. Collect a sputum sample.: Sputum collection is not typically indicated for epiglottitis diagnosis. A rapid diagnosis is essential to ensure timely intervention, and sputum samples are not a key diagnostic tool for this condition.

C. Determine the preschooler's oxygen saturation level.: Epiglottitis can lead to significant airway obstruction, so monitoring the oxygen saturation level is critical to assess for hypoxia and ensure adequate oxygenation. Early intervention may be required to maintain the child's airway.

D. Obtain a specimen for throat culture.: A throat culture should not be obtained in suspected epiglottitis, as manipulating the throat could cause complete airway obstruction. Immediate intervention to secure the airway is the priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting with the care of a preschooler who has manifestations that suggest epiglottitis. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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