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 C
Explanation
A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.
B. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D. Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.
Correct Answer is C
Explanation
A. Telling the child that it will not hurt may not be effective, as children may still have anxiety or fear related to the unknown.
B. Forcing a child or having the parent hold tightly may increase anxiety and make the child more resistant to the procedure.
C. Allowing the child to operate the equipment can give the child a sense of control and involvement, increasing cooperation.
D. Deferring the procedure until the next visit may not be practical or necessary if alternative strategies can be employed to promote cooperation.
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