A nurse is preparing to perform a capillary blood glucose test for a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?
Cleanse the client's finger with an antiseptic swab.
Hold the client's finger in a dependent position.
Wipe away the first drop of blood.
Place the lancet on the side of the selected finger.
The Correct Answer is A
A) Cleanse the client's finger with an antiseptic swab: The first step in performing a capillary blood glucose test is to cleanse the client’s finger with an antiseptic swab. This reduces the risk of infection and ensures that any contaminants on the skin do not affect the accuracy of the blood glucose reading.
B) Hold the client's finger in a dependent position: Holding the finger in a dependent position can help increase blood flow, but this step is taken after cleansing the finger. The priority is to first clean the area to minimize the risk of infection.
C) Wipe away the first drop of blood: Wiping away the first drop of blood is done to avoid contamination from interstitial fluid and to ensure a more accurate reading. However, this action occurs after the blood sample is obtained, not before the test begins.
D) Place the lancet on the side of the selected finger: While placing the lancet on the side of the finger is important for minimizing discomfort and obtaining an adequate blood sample, it follows the initial steps of cleaning the finger and preparing for the blood draw.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Manic behavior: Hyperthyroidism can lead to manic or hyperactive behavior due to increased metabolic rate and overstimulation of the nervous system. This may present as irritability, anxiety, or restlessness, making manic behavior a relevant manifestation in this condition.
B) Deep, labored respirations: Hyperthyroidism generally does not cause deep, labored respirations. Instead, it may lead to increased respiratory rate due to heightened metabolic activity. Deep, labored respirations are more indicative of respiratory or cardiac issues rather than hyperthyroidism.
C) Bradycardia: Hyperthyroidism usually causes tachycardia (elevated heart rate) rather than bradycardia (slow heart rate). Tachycardia is a common symptom due to the increased metabolic rate and sympathetic nervous system activity associated with hyperthyroidism.
D) Cold intolerance: Cold intolerance is more characteristic of hypothyroidism, where there is decreased metabolic activity and reduced heat production. Hyperthyroidism typically causes heat intolerance due to the increased metabolic rate and elevated body temperature.
Correct Answer is D
Explanation
A) Dyspepsia:
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease, causing discomfort in the upper abdomen. While it is uncomfortable and should be managed, it is not immediately life-threatening and does not require urgent intervention compared to other symptoms.
B) Nausea:
Nausea can be a distressing symptom associated with peptic ulcer disease, often resulting from irritation of the stomach lining. Although it can significantly impact the client’s well-being and appetite, it is not as critical as symptoms indicating active bleeding or more severe complications.
C) Hyperactive bowel sounds:
Hyperactive bowel sounds may be present in peptic ulcer disease due to increased gastrointestinal activity. This finding suggests heightened digestive activity but does not indicate an immediate life-threatening condition that would take precedence over signs of active bleeding.
D) Hematemesis:
Hematemesis, or vomiting blood, is a serious and potentially life-threatening symptom that indicates active gastrointestinal bleeding. This requires immediate medical attention to prevent significant blood loss, shock, and other complications. It is the priority finding because it poses the most immediate risk to the client’s health and stability.
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