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.)

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

Apply clean gloves.

Prick the side of the client's finger.

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

Cleanse the client's finger with an iodine swab.

Answer and Explanation

Correct Answer : B,C

A. Squeezing the client's finger until a blood drop forms can result in hemolysis and inaccurate results; instead, gentle milking or massaging of the finger is recommended.
B. Applying clean gloves is necessary to maintain infection control practices.

C.   Pricking the side of the client's finger is the appropriate technique for obtaining a capillary blood specimen.

D.   Elevating the client's hand above the level of the heart is not necessary and may impede blood flow.
E.   Cleansing the client's finger with an iodine swab helps to disinfect the area prior to obtaining the blood specimen.

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Correct Answer is B

Explanation

A. Using overhead lighting can disrupt the client's sleep by increasing stimulation; instead, use minimal lighting during nighttime assessments.
B. Keeping the door to the client's room closed can help reduce noise and disturbances from the hallway, promoting a more conducive sleep environment.
C. Providing snug-fitting nightwear may not directly address the underlying causes of insomnia and might not be effective for all clients.

D. Administering diuretics in the evening may exacerbate nocturia and disrupt sleep patterns; instead, diuretics are typically given earlier in the day to minimize nighttime urination.

A. Use a 10-mL syringe filled with cleansing solution. B. Dry the wound bed with gauze squares. C. Cleanse the wound with cotton balls. D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.

Correct Answer is A

Explanation

A. Using a 10-mL syringe filled with cleansing solution provides appropriate pressure for effective wound irrigation.
B. Drying the wound bed with gauze squares is not typically recommended as it may disrupt healing and cause trauma to the wound.
C. Cleansing the wound with cotton balls may leave fibers behind and is not the most effective method of wound irrigation.
D. Holding the syringe tip 2.5 cm (1 in) above the wound is incorrect; the tip should be inserted into the wound to facilitate thorough irrigation.

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