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

Puncture the side of the client's finger.

Position the client's finger above their heart.

Milk the finger site.

Apply sterile gloves prior to performing the test.

Answer and Explanation

The Correct Answer is A

Capillary blood glucose monitoring is a routine nursing procedure used to assess a client’s current blood glucose level, particularly in clients with diabetes mellitus or those at risk for hypo- or hyperglycemia. Proper technique is essential to ensure an accurate reading and to minimize discomfort and tissue damage. Correct site selection, adequate blood flow, and appropriate infection control practices are key components of the procedure. Errors in technique can lead to inaccurate results and inappropriate clinical decisions.

Rationale:
A. Puncturing the side of the finger is the recommended technique because this area has fewer nerve endings and causes less pain. It also provides adequate capillary blood flow for an accurate sample. The lateral aspect of the fingertip reduces tissue trauma and improves patient comfort during repeated testing.

B. Positioning the client’s finger above the heart is incorrect because it can reduce capillary blood flow to the puncture site. Lowering the hand below heart level is preferred to promote adequate perfusion and ensure sufficient blood sample collection. Elevation may result in difficulty obtaining an adequate drop of blood.

C. Milking the finger site is not recommended because it can cause tissue fluid contamination of the blood sample. This may dilute the capillary blood and result in falsely low or inaccurate glucose readings. Gentle pressure away from the puncture site may be used instead if needed.

D. Sterile gloves are not required for routine blood glucose monitoring because the procedure is not considered sterile. Clean gloves are appropriate since the task involves contact with intact skin and a small puncture. Using sterile gloves unnecessarily increases cost without improving patient safety.

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Correct Answer is B

Explanation

Tuberculosis is a highly contagious airborne infection caused by Mycobacterium tuberculosis. It spreads through airborne droplet nuclei that remain suspended in the air and can be inhaled by others. Infection control requires strict airborne precautions to prevent transmission to healthcare workers and other patients. Proper use of personal protective equipment is essential during routine care to reduce exposure risk.

Rationale:
A. Shoe protectors are not required for tuberculosis isolation because the organism is not transmitted through contact with footwear or contaminated floors. TB spreads through airborne particles rather than environmental surface contamination. Therefore, shoe covers do not provide meaningful protection.

B. An N95 respirator is required because it filters airborne particles and protects the nurse from inhaling droplet nuclei containing Mycobacterium tuberculosis. It is specifically designed for airborne precautions and must be properly fitted to ensure effectiveness. This is the appropriate PPE for routine care of a client with active tuberculosis.

C. A surgical mask is not sufficient protection against airborne pathogens like tuberculosis because it does not filter small aerosolized particles effectively. Surgical masks are intended for droplet precautions, not airborne isolation. A surgical mask does not provide adequate protection for healthcare workers in this situation.

D. Sterile gloves are not required for routine care of a client with tuberculosis unless sterile procedures are being performed. While gloves are used for contact with body fluids, they do not protect against airborne transmission. The primary protective equipment needed is respiratory protection rather than sterile hand protection.

A. Decreased skin turgor B. Pain relieved by analgesia C. Sensation of tingling D. Pale-colored toes E. Diminished capillary refill

Correct Answer is ["C","D","E"]

Explanation

Compartment syndrome is a serious complication that can occur after cast placement, fractures, or trauma when increased pressure within a closed muscle compartment impairs circulation and nerve function. Reduced blood flow leads to tissue ischemia, nerve damage, and possible permanent loss of function if not treated quickly. Early recognition is essential because it is considered an orthopedic emergency. Nurses assess for neurovascular compromise using key findings such as pain, pallor, paresthesia, pulselessness, paralysis, and delayed capillary refill.

Rationale:
A. Decreased skin turgor is a sign more commonly associated with dehydration rather than compartment syndrome. It reflects fluid volume deficit and does not indicate impaired circulation within an extremity. Neurovascular findings such as pain, pallor, and paresthesia are more specific indicators of compartment syndrome.

B. Pain relieved by analgesia is not expected in compartment syndrome because the pain is typically severe, persistent, and often unrelieved by standard pain medication. Pain that is disproportionate to the injury and worsens with passive movement is a classic early sign. Relief with analgesics would make compartment syndrome less likely.

C. Sensation of tingling is an important manifestation of compartment syndrome and reflects paresthesia caused by nerve compression and decreased perfusion. As pressure increases within the compartment, nerve function becomes impaired, leading to numbness, tingling, or burning sensations. This is an early warning sign that requires immediate attention.

D. Pale-colored toes indicate pallor caused by decreased arterial blood flow to the distal extremity. When compartment pressure rises, circulation becomes compromised and the skin may appear pale, cool, or cyanotic. This finding suggests reduced perfusion and is a significant sign of compartment syndrome.

E. Diminished capillary refill is a sign of impaired peripheral circulation and occurs when blood flow to the distal tissues is reduced. Delayed refill indicates vascular compromise and supports concern for compartment syndrome. This finding requires urgent assessment to prevent permanent tissue damage and loss of limb function.

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

Nursing Test Bank

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Correct Answer is B

Explanation

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