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 B

Explanation

Rationale:

A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.

B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.

C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.

D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.

A. Maintain the client in high-Fowler's position. B. Increase the client's intake of oral fluids. C. Instruct the client to cough every 4 hr. D. Encourage the client to ambulate to loosen secretions.

Correct Answer is A

Explanation

Rationale:

A. Maintain the client in high-Fowler's position: Placing the client in high-Fowler's position improves lung expansion and decreases pulmonary congestion by lowering venous return to the heart. This is a priority intervention for managing dyspnea and crackles in heart failure.

B. Increase the client's intake of oral fluids: Increasing fluid intake may worsen fluid overload in clients with heart failure. These clients typically require fluid restrictions to prevent exacerbation of symptoms like pulmonary edema.

C. Instruct the client to cough every 4 hr: While coughing can help clear secretions, the symptoms in this scenario are related to fluid overload, not mucus accumulation. Coughing alone will not relieve the pulmonary congestion seen in heart failure.

D. Encourage the client to ambulate to loosen secretions: Ambulation has benefits but is not the first action when the client is short of breath and showing signs of pulmonary congestion. Activity should be limited until respiratory status stabilizes.

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