A nurse is performing blood glucose monitoring on a client. Which of the following actions should the nurse take?
Position the client's finger above their heart.
Apply sterile gloves prior to performing the test.
Puncture the side of the client's finger.
Milk the finger site.
The Correct Answer is C
A. Position the client's finger above their heart: The finger should be positioned below the level of the heart to encourage blood flow, making it easier to obtain a sufficient blood sample for testing. Elevating the finger would decrease blood flow and make collection more difficult.
B. Apply sterile gloves prior to performing the test: Clean, non-sterile gloves are sufficient for routine blood glucose monitoring. Sterile gloves are not necessary unless performing procedures that require a sterile environment, such as surgery or central line dressing changes.
C. Puncture the side of the client's finger: The sides of the fingertips have fewer nerve endings compared to the pads, making the procedure less painful. Additionally, puncturing the side helps promote better blood flow and reduces the risk of bruising and soreness.
D. Milk the finger site: Milking or squeezing the finger excessively can cause hemolysis or contamination of the blood sample with tissue fluid, leading to inaccurate glucose readings. Gentle pressure may be used if needed, but forceful milking should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Drink high-protein nutritional supplements between meals: Clients with COPD often experience anorexia due to fatigue, difficulty breathing while eating, and early satiety. High-protein, high-calorie supplements between meals help meet nutritional needs without overwhelming them during main meals, supporting energy levels and respiratory muscle strength.
B. Eat more hot foods than cold foods at mealtime: Hot foods can produce stronger odors that may worsen appetite loss. Cold foods tend to have milder smells and may be better tolerated by clients with anorexia, making cold foods preferable rather than focusing on hot foods.
C. Eat low-calorie foods first at mealtime: Clients with anorexia and COPD should prioritize high-calorie, nutrient-dense foods first to maximize intake before feeling full. Eating low-calorie foods first could reduce overall calorie intake, worsening weight loss and malnutrition risks.
D. Increase liquids during meals: Consuming large amounts of liquid during meals can cause early satiety, making it harder for clients to consume enough food. It is better to encourage drinking fluids between meals to optimize food intake during eating times.
Correct Answer is A
Explanation
A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.
B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.
C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.
D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.
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