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,E

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 C

Explanation

A. Documenting client education on self-care needs is important but does not specifically relate to the postpartum status or immediate healthcare concerns.
B. While documenting vital signs like oral temperature is important for monitoring the client's health, this specific finding does not relate directly to the postpartum status unless it is elevated beyond normal ranges and indicates a potential complication.
C. Documenting the condition of the episiotomy site, including its approximation and length, is essential for assessing wound healing and preventing infection in the postpartum period.

D. While hydration is important for postpartum recovery, documenting fluid intake is not as crucial as assessing the healing of specific postpartum interventions like an episiotomy.

A. "I should wear shoes with smooth soles to help slide my weak leg forward." B. "I will move the cane forward 18 inches." C. "I will hold the cane on my stronger side." D. "I should move my stronger leg forward before moving my weaker leg."

Correct Answer is C

Explanation

A. Wearing shoes with smooth soles may increase the risk of slipping and falling, especially for a client with mobility issues. It is not a safe recommendation.
B. Moving the cane forward 18 inches is too far and may lead to instability during ambulation.
Typically, the cane should be moved forward only about 6 to 12 inches.

C. Holding the cane on the stronger side provides better support and stability, as it allows the client to bear weight on the stronger side while using the cane for balance and support on the weaker side.
D. Moving the stronger leg forward before the weaker leg is a correct step in the gait pattern when using a cane or other assistive device for walking. However, the statement does not
specifically address the use of the quad cane.

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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

A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?

Correct Answer is C

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Correct Answer is C

Explanation

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