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 ["A","B","C","E"]

Explanation

Rationale:

• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.

• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.

• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.

• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.

• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.

A. Nurse addressing the client directly while the interpreter is present. B. Nurse asking the client for questions at the end of the instructions. C. Staff member serving as an interpreter for the client. D. Family member acting as an interpreter for the client.

Correct Answer is A

Explanation

Rationale:

A. Nurse addressing the client directly while the interpreter is present: This demonstrates culturally competent and client-centered care. Documenting that the nurse communicated directly with the client through a qualified interpreter shows appropriate use of interpretation services and respect for the client's autonomy.

B. Nurse asking the client for questions at the end of the instructions: While this is good practice, it does not specifically demonstrate that the client's language needs were addressed. Without interpreter documentation there’s no assurance the client understood the information.

C. Staff member serving as an interpreter for the client: Unless the staff member is a certified medical interpreter, using them for interpretation may result in miscommunication and is not best practice. Documentation should reflect use of trained professionals.

D. Family member acting as an interpreter for the client: Family members should not be used for interpretation due to risks of bias, inaccuracies, and privacy violations. Professional interpreters are necessary to ensure accurate, safe, and confidential communication.

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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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