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.
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.
Apply clean gloves.
Correct Answer : B,E
A. Squeezing the client’s finger should be avoided as it can cause hemolysis and affect the accuracy of the blood sample.
B. Pricking the side of the client’s finger is recommended as it tends to be less painful and reduces tissue damage.
C. Elevating the hand above the heart level could reduce blood flow, making it more difficult to obtain a sample.
D. An alcohol swab, not iodine, is typically used to cleanse the site for a capillary blood draw, as iodine can interfere with certain lab results.
E. Applying clean gloves is a standard precaution to prevent contamination and protect both the nurse and the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The best time for breast self-examination is usually about a week after the period starts when the breasts are less tender.
B. During perimenopause, menstrual cycles can become irregular; the client may not have regular periods until menopause.
C. Declining estrogen levels during perimenopause can indeed lead to various symptoms, including headaches, indicating the client understands the information.
D. Women should continue to receive Papanicolaou tests as recommended by their healthcare provider even after menopause, so this statement is incorrect.
Correct Answer is ["A","B","C","E","F"]
Explanation
Deep Tendon Reflexes 4+: This indicates hyperreflexia, which can be associated with electrolyte imbalances, particularly magnesium deficiency, or central nervous system issues. In this context, the client has a low magnesium level (0.7 mEq/L), which can cause neuromuscular irritability and potentially dangerous complications.
Generalized Weakness and Mild Leg Cramping: While muscle strength is reported as equal, the generalized weakness and cramping suggest possible electrolyte imbalances or neurological issues. The combination with low magnesium levels raises concern for further complications.
Heart Rate Irregular: An irregular heart rate can indicate potential cardiac issues, especially in the context of electrolyte imbalances such as hypomagnesemia and the use of hydrochlorothiazide, which can contribute to electrolyte disturbances.
Bowel Sounds Hyperactive x 4 Quadrants: Although hyperactive bowel sounds can be associated with various conditions, in this case, they may be linked to the client's history of vomiting and possible electrolyte imbalance, warranting follow-up to ensure appropriate management of gastrointestinal symptoms.
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