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. "Why don't you want to be touched?": Asking "Why" can make a client feel defensive and is considered non-therapeutic communication.

B. "Would you like some pain medication before getting out of bed?": This ignores the client's immediate assertion of independence and safety risk.

C. "I will stand next to you and help if you need me to.":. This response respects the client's autonomy while ensuring safety by maintaining proximity in case the client becomes unsteady.

D. "We can talk about this after you have gotten out of bed.": This dismisses the client's immediate concern and the potential risk of a fall.

A. Lower extremity weakness B. Reduced health literacy C. Texting while driving D. Impaired hearing

Correct Answer is C

Explanation

A. Lower extremity weakness: This is a physiological or physical risk factor, not a lifestyle choice.

B. Reduced health literacy: This is a socioeconomic or cognitive factor.

C. Texting while driving: A lifestyle risk factor is a behavior or habit that an individual chooses to engage in which increases their risk of harm.

D. Impaired hearing: This is a sensory/physiological risk factor.

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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.)

Nursing Test Bank

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