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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chicken sandwich is correct. In kosher dietary practices, poultry such as chicken is allowed, as long as it is prepared according to kosher guidelines. It is permissible for a client who follows kosher dietary practices to have a chicken sandwich, provided the bread and other ingredients are also kosher.
B. Cheeseburger is incorrect. Kosher dietary laws prohibit mixing meat and dairy. A cheeseburger would violate this rule because it contains both meat (beef) and dairy (cheese..
C. Shrimp and french fries is incorrect. Shellfish, including shrimp, is not allowed in a kosher diet. Kosher dietary practices prohibit eating shellfish and other non-kosher seafood.
D. Bacon and eggs is incorrect. Pork products, including bacon, are strictly forbidden in kosher dietary practices, so this would not be an appropriate choice for a client following kosher dietary laws.
Correct Answer is B
Explanation
A. Administer an anti-anxiety medication is not the first action. The nurse should first assess and manage the client's environment and emotional state before resorting to medication.
B. Minimize environmental stimuli in the client's surroundings is correct. The client is experiencing anxiety, and minimizing stimuli helps to reduce environmental triggers and can immediately alleviate distress.
C. Explore behaviors that have helped to reduce the client's anxiety in the past is a good intervention but should not be the first response. The immediate priority is to reduce the anxiety by controlling the environment.
D. Explain to the client that anxiety causes physical manifestations is helpful but should occur after the immediate anxiety-reduction measures are in place. Providing this information can be part of the therapeutic process but does not address the client’s immediate distress.
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