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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Keep client in semi-Fowler's position with right extremity flat: Semi-Fowler's position is not optimal for a client with a compound fracture of the right tibia. Elevating the affected extremity, rather than keeping it flat, can help reduce swelling and pain.

B) Manage pain with oral opioids every 6 hr: While managing pain is crucial, oral opioids may not provide immediate relief needed in acute settings. Pain management should include a combination of strategies and may require IV analgesics for quicker relief.

C) Check capillary refill hourly for the first 24 hr: Although monitoring capillary refill is important to assess circulation, it is only one aspect of monitoring. Comprehensive assessment includes checking for signs of infection, neurovascular status, and compartment syndrome.

D) Apply a compression dressing over the fracture site: Applying a compression dressing can help control bleeding and reduce swelling. In a compound fracture, managing external bleeding and providing some stability to the fracture site are immediate priorities. However, the nurse should ensure this is done without compromising circulation and should be guided by physician orders.

A. HDL 65 mg/dL B. LDL 120 mg/dL C. Cholesterol 195 mg/dL D. Triglycerides 175 mg/dL

Correct Answer is B

Explanation

A) HDL 65 mg/dL: High-density lipoprotein (HDL) levels of 65 mg/dL are considered protective against heart disease. Higher HDL levels are generally associated with a lower risk of cardiovascular disease, so this result is not a concern.

B) LDL 120 mg/dL: Low-density lipoprotein (LDL) levels of 120 mg/dL are elevated for individuals at increased risk of cardiovascular disease, especially with a family history of hyperlipidemia and cardiac disease. An LDL level above 100 mg/dL is a risk factor for heart disease, making this result important to report to the provider for potential intervention.

C) Cholesterol 195 mg/dL: A total cholesterol level of 195 mg/dL is slightly above the recommended level of less than 200 mg/dL but may not be immediately alarming unless the client has other risk factors. However, this value alone is not as critical as LDL levels in assessing risk.

D) Triglycerides 175 mg/dL: Triglyceride levels of 175 mg/dL are slightly elevated, as normal levels are typically less than 150 mg/dL. While elevated triglycerides are a risk factor for cardiovascular disease, this level is less critical compared to elevated LDL levels in the context of the client’s family history.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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