A nurse is preparing to measure a post-meal blood glucose level in a patient with diabetes mellitus. What steps should the nurse take?
Prick the central tip of the patient’s finger.
Apply the first drop of blood to the test strip.
Hold the patient’s finger in a dependent position.
Clean the patient’s finger with hexachlorophene.
The Correct Answer is C
A. Prick the central tip of the patient’s finger: The central tip of the finger has more nerve endings, making it more painful. Instead, the side of the fingertip should be used because it has fewer nerve endings and promotes better blood flow.
B. Apply the first drop of blood to the test strip: The first drop of blood may contain interstitial fluid or contaminants (e.g., alcohol residue), leading to inaccurate readings. Instead, the first drop should be wiped away, and the second drop should be used for testing.
C. Hold the patient’s finger in a dependent position: Holding the finger in a dependent position (below heart level) helps increase blood flow to the fingertip, making it easier to obtain an adequate blood sample without excessive squeezing, which could dilute the sample with tissue fluid.
D. Clean the patient’s finger with hexachlorophene: Hexachlorophene is not recommended for skin antisepsis before blood glucose testing. Instead, alcohol wipes or soap and water should be used. The finger should be fully dried before pricking to avoid dilution of the blood sample.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Bulging skin around the stoma can be a sign of a hernia, but it’s not uncommon in the early postoperative period. It should be monitored, but it’s not typically a cause for immediate concern.
Choice B rationale
A stoma that protrudes 2 cm (0.8 in) above the abdominal wall is considered normal. The stoma should protrude above the skin to prevent stool from coming into contact with the skin, which can cause irritation and breakdown.
Choice C rationale
A stoma that is moist and beefy red is a sign of a healthy stoma. This indicates that the stoma has a good blood supply and is not ischemic or necrotic.
Choice D rationale
No fecal output from the stoma 24 hours after surgery could indicate a blockage or other complication and should be reported to the provider immediately.
Correct Answer is C
Explanation
A.Changing the dressing on the tracheostomy site is an important part of tracheostomy care, but it is not the first action that should be taken.
B.Suctioning the tracheostomy tube should only be performed if there are signs of airway obstruction (e.g., increased secretions, decreased oxygenation, or adventitious breath sounds). Suctioning too frequently or unnecessarily can cause mucosal damage and hypoxia.
C. Auscultating the lungs helps the nurse determine if there is increased secretions, diminished breath sounds, or other airway concerns that may require suctioning. This ensures that care is performed appropriately based on the client’s needs.
D.Cleaning the inner cannula is a necessary part of tracheostomy care, but it should bedone after assessing the airway and performing suctioning if needed.
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