A nurse is teaching a client who has diabetes mellitus about self-monitoring of blood glucose levels at home.
Which of the following instructions should the nurse include in the teaching?
"Wash your hands with warm water and soap before testing."
"Use alcohol wipes to clean your finger before pricking it."
"Squeeze your finger firmly to obtain a drop of blood."
"Choose a different finger for each test throughout
The Correct Answer is A
"Wash your hands with warm water and soap before testing."
Rationale: The nurse should instruct the client to wash their hands with warm water and soap before testing, as this helps to prevent infection and remove any substances that may interfere with the accuracy of the test result.
Incorrect options:
B) "Use alcohol wipes to clean your finger before pricking it." - This is an incorrect instruction, as using alcohol wipes to clean the finger can dry out and irritate the skin, and may also affect the test result if the alcohol is not completely dry before pricking.
C) "Squeeze your finger firmly to obtain a drop of blood." - This is an incorrect instruction, as squeezing the finger firmly can cause hemolysis or dilution of the blood sample, leading to inaccurate readings. The client should apply gentle pressure to the finger after pricking it.
D) "Choose a different finger for each test throughout the day." - This is an incorrect instruction, as choosing a different finger for each test throughout the day can increase the risk of infection and pain. The client should rotate the testing sites within one finger or use alternate sites, such as the forearm or palm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Potassium 5.5 mEq/L
Rationale: The nurse should report the potassium level of 5.5 mEq/L to the provider before proceeding with
the blood transfusion, as this indicates hyperkalemia, which can cause cardiac arrhythmias or arrest. Blood transfusion can increase potassium levels further, especially if the blood has been stored for a long time or if it is administered rapidly.
Incorrect options:
A) Hemoglobin 8 g/dL - This is a low hemoglobin level, which indicates anemia, but it is not a contraindication for blood transfusion. In fact, blood transfusion may be indicated to treat severe anemia and improve oxygen delivery to the tissues.
B) Platelets 150,000/mm3 - This is a normal platelet count, which indicates adequate clotting function. It is not a reason to withhold or delay blood transfusion.
D) Blood type AB positive - This is the client's blood type, which is compatible with any blood type for transfusion, as AB positive is the universal recipient. It is not a reason to report to the provider or stop the transfusion.
Correct Answer is D
Explanation
The presence and quality of pedal pulses on both legs.
Rationale: The nurse should obtain information on the presence and quality of pedal pulses on both legs from the report, as this indicates the adequacy of blood circulation and perfusion to the lower extremities, which can be compromised by surgery, positioning, or complications such as thromboembolism or compartment syndrome.
Incorrect options:
A) The type and size of the prosthesis used may be important information for the surgical team and the client's medical record, but it is not immediately relevant to the immediate post-operative care provided by the nurse.
B) The amount and color of urine output during surgery is not directly related to the client's condition after a total hip arthroplasty and is not the primary focus of the nurse's assessment at this time.
C) The type and dose of anesthesia administered is important information for the client's medical record and may have implications for post-operative care, but it is not the most critical information for the nurse to obtain immediately upon receiving the report.
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