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 D

Explanation

A. Increasing protein intake is not directly related to preventing orthostatic hypotension. While adequate nutrition is essential for overall health and healing postoperatively, it does not
specifically address the risk of orthostatic hypotension.

B. Using an incentive spirometer is beneficial for promoting lung expansion and preventing respiratory complications after surgery but does not directly address orthostatic hypotension.
C. Performing regular isometric exercises may help prevent muscle atrophy and maintain

strength during periods of immobility but does not specifically address orthostatic hypotension.

D. Dangling the legs over the side of the bed before standing helps the body gradually adjust to an upright position, reducing the risk of orthostatic hypotension by allowing the cardiovascular system to acclimate to changes in posture.

A. Complete an incident report about the breach of confidentiality. B. Tell the nurse that permission from the risk manager is required to view the client's record. C. Remind the nurse that only staff caring for the client may access the client's record. D. Contact facility security to remove the nurse from the unit.

Correct Answer is C

Explanation

A. Completing an incident report about the breach of confidentiality may be necessary, but it

should not be the first action. The immediate concern is addressing the behavior and reminding the nurse of proper protocol.
B. While it may be true that permission from the risk manager is required to access certain

records, this response does not address the immediate issue of the unauthorized access. It's more important to address the behavior directly.

C. This is the most appropriate action because it directly addresses the unauthorized access to the client's medical record. Reminding the nurse of the proper protocol for accessing medical records can help prevent further breaches of confidentiality.
D. Contacting facility security to remove the nurse from the unit may be excessive at this stage and should be considered if the behavior persists after reminders about proper protocol.

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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

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Correct Answer is C

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