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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B. Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C. Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D. Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

A. "Raise your head off the pillow." B. "Bear down." C. "Hold your breath." D. "Perform Kegel exercises."

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Correct Answer is B

Explanation

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to help ease the passage of the catheter through the urinary meatus?

Correct Answer is B

Explanation

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