A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

Elevate the client's hand above the level of the heart.

Squeeze the client's finger until a blood drop forms.

Prick the side of the client's finger.

Apply clean gloves.

Cleanse the client's finger with an iodine swab.

Answer and Explanation

Correct Answer : C,D

A. Elevate the client's hand above the level of the heart.: The hand should be kept dependent (below heart level) to increase blood flow to the fingertips.

B. Squeeze the client's finger until a blood drop forms.: Excessive squeezing (milking) can cause hemolysis or dilute the specimen with interstitial fluid.

C. Prick the side of the client's finger.: The sides of the finger have fewer nerve endings and better vascularity than the center of the fingertip.

D. Apply clean gloves.: Standard precautions must be followed when handling blood.

E. Cleanse the client's finger with an iodine swab.: Iodine can interfere with results (especially glucose). Alcohol is typically used and must be allowed to dry completely.

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Correct Answer is C

Explanation

A. Mark the length to be inserted on the tube with tape.: This is done after the pathway is assessed but before insertion.

B. Place a water-based lubricant on the tip of the tube.: This is done immediately before insertion, not as the first step.

C. Compare the patency of the client's nares.: Following the Nursing Process (Assessment first), the nurse must determine which nostril is most patent to ensure the easiest passage for the tube.

D. Instruct the client to hyperextend her neck.: This is a position used during the initial insertion phase, but assessment of the nares must come first.

A. Add liquid to foods to thin consistency. B. Tilt the client's head slightly backward. C. Encourage socialization with others during meals. D. Provide mouth care before the client eats.

Correct Answer is D

Explanation

A. Add liquid to foods to thin consistency.: Thin liquids are actually the most difficult to swallow and increase the risk of aspiration. Foods should be thickened to a "nectar" or "honey" consistency as prescribed.

B. Tilt the client's head slightly backward.: This opens the airway. For safe swallowing, the client should use the "chin-tuck" method (tilting the head forward/down) to help close the trachea and open the esophagus.

C. Encourage socialization with others during meals.: Clients with dysphagia should focus entirely on chewing and swallowing to prevent aspiration; talking while eating increases risk.

D. Provide mouth care before the client eats.: Oral hygiene before meals stimulates the appetite and removes bacteria from the mouth. If a client does aspirate, they are less likely to develop pneumonia if their oral cavity is clean.

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A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is D

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