A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?
Wrapping the finger in a warm cloth
Rubbing the fingertip with an alcohol pad
Puncturing the side of the fingertip
Elevating the finger above heart level
The Correct Answer is D
A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.
C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.
D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.
B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.
Correct Answer is B
Explanation
A. Expressing a desire to understand why the amputation happened suggests the client is still grappling with acceptance.
B. Expressing discomfort with therapy but being comfortable with the prosthesis indicates an acknowledgment of the loss and adaptation to the situation.
C. Noting the leg's appearance and healing is an observation but does not necessarily indicate acceptance.
D. Indicating a readiness to talk about the leg in a week or so suggests the client is not currently ready to discuss or fully accept the loss.
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