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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "I will irrigate the colostomy every day.": Colostomy irrigation is used for descending or sigmoid colostomies to regulate bowel movements. It is not recommended for ascending colostomies because the stool is too liquid and unpredictable for effective irrigation.
B. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should be pink or red and moist. A purple or dusky appearance suggests compromised blood flow or ischemia and should be reported to the provider immediately as it may indicate a serious complication.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is generally liquid to semi-liquid due to the location in the digestive tract. Formed stool is more typical of descending or sigmoid colostomies, not ascending ones.
D. "I will no longer be able to eat nuts.": While some clients may choose to avoid certain foods based on personal tolerance, there is no absolute dietary restriction against nuts for colostomy clients unless otherwise advised.
Correct Answer is ["A","B","D","G","H"]
Explanation
Rationale:
• An older adult client is at high risk for delirium due to age-related changes in the brain and reduced physiological reserve. ICU environments and acute illness increase susceptibility in older adults. Age over 65 is a primary risk factor in many validated delirium screening tools.
• Fever and hypotension suggest a systemic infection and possible sepsis, which can impair cerebral perfusion. This can trigger acute confusion or delirium, especially in vulnerable individuals. The combination of infection and low blood pressure disrupts normal brain function.
• Total left hip arthroplasty involves major surgery and potential postoperative complications such as infection or pain. Surgical trauma, anesthesia, and immobility all increase delirium risk. Recent surgery also increases inflammatory cytokine activity affecting cognition.
• Past medical history: Parkinson’s disease is linked to higher delirium risk due to existing neurotransmitter imbalances. The condition often coexists with cognitive decline or medication interactions. Parkinson’s-related brain changes make acute confusion more likely.
• Visual loss without glasses limits sensory input and orientation cues, contributing to perceptual disturbances. Poor vision can lead to misinterpretation of surroundings, promoting hallucinations or paranoia. Environmental disorientation is a key factor in ICU-related delirium.
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