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 B
Explanation
A. Amyloid plaque: Amyloid plaque buildup is characteristic of Alzheimer’s disease, a chronic, progressive form of dementia. While dementia can increase the overall risk for delirium, amyloid plaques themselves are not an immediate trigger for acute confusion like delirium.
B. Urinary tract infection: Urinary tract infections are a common reversible cause of delirium, especially in older adults. Infections can trigger a systemic inflammatory response and disrupt normal brain function, leading to sudden-onset confusion, disorientation, and restlessness due to systemic inflammation and changes in metabolic balance.
C. High cholesterol: High cholesterol contributes to long-term cardiovascular risks, such as atherosclerosis and stroke, but it is not directly linked to the sudden cognitive changes seen in delirium. It does not cause the acute neurological dysfunction characteristic of delirium.
D. Hypersomnia: Hypersomnia, or excessive daytime sleepiness, may reflect underlying sleep disorders or other chronic conditions, but it is not recognized as a common direct cause of delirium. Acute changes in mental status are more often tied to factors like infection, medications, or metabolic disturbances.
Correct Answer is C
Explanation
A. Inability to read: Difficulty reading is not a hallmark symptom of delirium. It may be associated with visual impairment, literacy issues, or chronic cognitive decline such as dementia, but delirium is primarily characterized by acute mental status changes, not isolated reading difficulties.
B. Echopraxia: Echopraxia, the involuntary imitation of another person’s movements, is typically associated with schizophrenia or other severe psychiatric disorders. It is not a defining feature of delirium, which primarily affects attention, awareness, and cognition rather than imitation behaviors.
C. Acute onset of confusion: Delirium is distinguished by a sudden, acute onset of confusion and fluctuating levels of consciousness. Clients may exhibit disorganized thinking, poor attention, and impaired awareness, which are hallmark features that help differentiate delirium from chronic conditions like dementia.
D. Aphasia: Aphasia, or loss of the ability to understand or express speech, is more commonly related to neurological injuries such as stroke. While speech may be disorganized during delirium, the specific loss of language function like aphasia is not a primary or expected feature of this acute condition.
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