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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Placing one crutch on each side when assuming a sitting position is not indicative of safe crutch use as it does not provide adequate support or balance during the transition from standing to sitting.
B) Placing weight on the axillae, or underarms, can cause nerve damage due to the pressure on the radial nerve located there; therefore, this is not a safe practice.
C) When descending stairs, the affected leg should be moved first, followed by the crutches and then the unaffected leg, to maintain balance and safety. Therefore, moving the unaffected leg onto a step first is not the safest option.
D) Having slightly flexed elbows allows for proper distribution of weight and helps in maintaining balance while ambulating with crutches, making it the correct and safe method.
Correct Answer is B
Explanation
A. Raising the head off the pillow is not relevant to easing the passage of the catheter through the urinary meatus.
B. Bearing down can help relax the pelvic floor muscles, making it easier to insert the catheter through the urinary meatus.
C. Holding the breath is not typically instructed during catheter insertion and may not aid in the ease of the procedure.
D. Performing Kegel exercises involves contracting pelvic floor muscles, which is not the desired action when inserting a urinary catheter.
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