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 A

Explanation

A. Decrease background noise.: Eliminating competing sounds (TV, hallway noise, fans) makes it easier for the client to focus on the nurse’s voice and prevents sound distortion.

B. Speak in a loud voice.: Incorrect. Shouting can distort the sound of words and often raises the pitch of the voice, which is usually the frequency most difficult for those with hearing loss to hear.

C. Talk at a rapid rate.: Incorrect. The nurse should speak slowly and clearly to allow the client time to process the information and potentially read lips.

D. Use short phrases.: While clarity is good, using "short phrases" can come across as "baby talk" or patronizing. Speaking in normal, clear sentences is preferred unless the client has a cognitive impairment.

A. Full range of motion bilateral lower extremities B. Hearing acuity intact C. Ability to use call light D. Oriented to person only

Correct Answer is D

Explanation

A. Full range of motion bilateral lower extremities: This is a normal finding and indicates the client has the physical strength and mobility to move safely.

B. Hearing acuity intact: Intact senses allow the client to hear alarms, instructions, and environmental cues, reducing injury risk.

C. Ability to use call light: This is a safety factor, as it means the client can summon help when needed.

D. Oriented to person only: A client who is only oriented to person (and not to place, time, or situation) is confused. Confusion is a major risk factor for falls, pulling at tubes, and other accidental injuries.

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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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