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 C

Explanation

A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.

B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.

C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.

D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.

A. Encourage the toddler to flush the toilet while still seated. B. Have the toddler remain on the toilet for a minimum of 20 min. C. Wake the toddler every 2 hr. in the night to prevent bed-wetting. D. Give the toddler a sticker after each successful toileting attempt.

Correct Answer is D

Explanation

A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.

D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.

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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

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