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 D
Explanation
A. Librium: Librium (chlordiazepoxide) is a benzodiazepine used primarily for anxiety and alcohol withdrawal management. It is not typically prescribed for pain control after surgery and would not be expected in a client using a PCA pump.
B. Disulfiram: Disulfiram is used to deter alcohol consumption by causing unpleasant effects when alcohol is ingested. It has no role in pain management and would not be associated with postoperative care or PCA use.
C. Phenobarbital: Phenobarbital is a barbiturate used to control seizures and sometimes for sedation. It is not prescribed for pain relief and would not be expected for a client recovering from a hysterectomy with a PCA pump.
D. Clonidine: Clonidine can be used as an adjunct to pain management, particularly to enhance the effects of opioids and reduce the amount needed. It can help manage withdrawal symptoms and pain, making it a medication the provider might prescribe alongside a PCA pump.
Correct Answer is C
Explanation
A. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows during a fire can cause the fire to spread more rapidly by feeding it with additional oxygen. Doors should be closed to contain the fire and reduce the spread of smoke.
B. Attempt to extinguish the fire before evacuating clients: Client safety is the priority in a fire situation. Evacuation should occur first, and attempts to extinguish the fire should only be made if it is safe to do so without putting clients or staff at risk.
C. Have ambulatory clients walk independently to a safe location: Ambulatory clients should be instructed to evacuate independently if they can do so safely, freeing staff to assist clients who are immobile or require more help during the evacuation.
D. Aim the spray of the fire extinguisher at the top of the fire: The proper technique is to aim at the base of the fire, not the top, to effectively extinguish the flames by removing the fire's source of fuel.
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