A nurse is performing a capillary blood glucose test on a client. Which of the following actions should the nurse take?

Don sterile gloves prior to the procedure.

Hold the finger in an upright position prior to the procedure.

Use the lateral tip of the finger to obtain specimen.

Discard the lancet in the trash container.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Don sterile gloves prior to the procedure: Clean gloves, not sterile gloves, are required for a capillary blood glucose test since it is a clean, not sterile, procedure. Sterile technique is unnecessary and not cost-effective for this type of routine testing.

B. Hold the finger in an upright position prior to the procedure: The finger should be held in a dependent (downward) position to promote blood flow to the puncture site. Holding it upright may reduce perfusion and make obtaining an adequate sample more difficult.

C. Use the lateral tip of the finger to obtain specimen: The lateral sides of the fingertip have fewer nerve endings than the center and are more vascular, making them ideal for obtaining an adequate blood sample with minimal discomfort to the client.

D. Discard the lancet in the trash container: Lancets are sharp instruments and must be discarded in an approved sharps container to prevent needle-stick injuries and ensure proper infection control. Disposing of them in regular trash poses a safety hazard.

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Correct Answer is D

Explanation

Rationale:

A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.

B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.

C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.

D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.

A. Beefy, red tongue B. Productive cough with thick mucous C. Facial erythema D. Koplik spots

Correct Answer is C

Explanation

Rationale:

A. Beefy, red tongue: A beefy, red tongue is typically associated with scarlet fever, not pertussis. It results from the streptococcal infection and accompanying inflammatory response, which is unrelated to the bacterial cause and symptom pattern of pertussis.

B. Productive cough with thick mucous: Pertussis, or whooping cough, usually causes a paroxysmal, dry, hacking cough followed by a characteristic "whooping" sound on inspiration. It is not commonly associated with a productive cough containing thick mucus, especially in early and peak stages.

C. Facial erythema: Facial erythema can occur during severe coughing fits in children with pertussis due to the forceful and prolonged nature of coughing episodes. The increased intrathoracic pressure during coughing may lead to flushing or redness of the face.

D. Koplik spots: Koplik spots are small, bluish-white lesions on the buccal mucosa and are an early sign of measles, not pertussis. They are not present in bacterial infections like Bordetella pertussis, which affects the respiratory tract.

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A nurse is performing a capillary blood glucose test on a client. Which of the following actions should the nurse take?

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