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) Aspirin can be given to decrease the fever caused by varicella: Aspirin should not be used in children with varicella (chickenpox) due to the risk of Reye’s syndrome, a rare but serious condition that can cause liver and brain damage. Instead, acetaminophen or ibuprofen is recommended for fever management in these cases.

B) Maintaining a warm environment decreases the eruption of lesions: Maintaining a warm environment does not affect the eruption of varicella lesions and could potentially exacerbate discomfort. A cool environment and loose, comfortable clothing are preferred to help alleviate itching and discomfort.

C) Varicella has an incubation period of 1 to 3 days: The incubation period for varicella is typically 10 to 21 days after exposure. The shorter period of 1 to 3 days is not accurate for varicella and does not reflect the standard incubation period of this disease.

D) An antihistamine can be administered to decrease pruritus: Antihistamines are effective in managing itching (pruritus) associated with varicella lesions. They can help provide relief from the discomfort caused by the rash, making this an appropriate intervention.

A. "I will offer my child apple juice instead of milk." B. "I should continue to feed my child when he pushes food out with his tongue." C. "I will provide his favorite food as a reward for good behavior." D. "I should increase my child's vitamin A intake by feeding him raw carrot slices."

Correct Answer is B

Explanation

A) "I will offer my child apple juice instead of milk.": Offering apple juice instead of milk is not ideal for a toddler with failure to thrive. Milk is a better source of essential nutrients like calcium and vitamin D, which are important for growth and development. Juice can contribute to empty calories and should be limited.

B) "I should continue to feed my child when he pushes food out with his tongue.": This statement indicates an understanding of the importance of addressing feeding difficulties. In toddlers with Down syndrome, it is common to experience difficulties with feeding and swallowing. Continuing to offer food and using techniques to encourage eating, even when the child initially pushes food out, can help ensure adequate nutritional intake and support growth.

C) "I will provide his favorite food as a reward for good behavior.": Using food as a reward can lead to unhealthy eating habits and an association of food with behavior rather than hunger and nutrition. It’s better to use non-food rewards to encourage positive behavior.

D) "I should increase my child's vitamin A intake by feeding him raw carrot slices.": While vitamin A is important, raw carrots can be difficult for toddlers, especially those with developmental delays or oral-motor difficulties, to chew and swallow. Cooked carrots or other vitamin A-rich foods might be a safer option.

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