A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?
Select the central tip of a finger.
Wear sterile gloves.
Keep the finger in a dependent position.
Milk or massage the finger site.
The Correct Answer is C
Choice A Reason:
Select the central tip of a finger is incorrect. The nurse should select a puncture site on the side of the finger, slightly off-center from the central tip, as it tends to be less painful. The side of the finger has an adequate blood supply and can provide an accurate blood sample without causing excessive discomfort.
Choice B Reason:
Wearing sterile gloves is incorrect. Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. However, clean hands and proper hand hygiene are essential. The nurse should perform hand hygiene before the procedure.
Choice C Reason:
Keeping the finger in a dependent position is correct. Keeping the finger in a dependent position (hanging down) can promote blood flow and make it easier to obtain a blood sample. This is a recommended technique to facilitate the puncture and collection of blood.
Choice D Reason:
Milking may hemolyze specimen and introduce excess tissue fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"Sounds are soft and at a rate of 1/min" - This describes hypoactive bowel sounds, which are characterized by decreased motility, not hyperactive bowel sounds.
Choice B Reason:
"Indicates decreased motility" - This is a correct statement about hypoactive bowel sounds, not hyperactive bowel sounds.
Choice C Reason:
Sounds are high-pitched. Hyperactive bowel sounds are characterized by sounds that are loud and high-pitched. These sounds are often more frequent and rapid than normal bowel sounds, indicating increased motility of the gastrointestinal tract. Hyperactive bowel sounds can be associated with conditions like diarrhea or early bowel obstruction and are the opposite of hypoactive bowel sounds, which are soft and indicate decreased motility. Paralytic ileus, on the other hand, is a condition that can lead to hypoactive or absent bowel sounds.
Choice D Reason:
"Can be a result of a paralytic ileus" - Paralytic ileus typically results in hypoactive or absent bowel sounds, not hyperactive bowel sounds.
Correct Answer is B
Explanation
Choice A Reason:
Requesting an x-ray of the preschooler's neck is not typically indicated for RSV. RSV primarily affects the respiratory system, and neck x-rays are not a standard diagnostic tool for this condition.
Choice B Reason:
Initiate droplet precautions are incorrect. This is the most appropriate action for RSV. RSV is primarily transmitted through respiratory droplets. Droplet precautions involve wearing a mask and maintaining a safe distance from the infected child to prevent the spread of the virus to others. It's a standard infection control measure for RSV.
Choice C Reason:
Monitoring the preschooler's urine for protein is not relevant to RSV. RSV primarily affects the respiratory system and does not typically cause kidney problems.
Choice D Reason:
Administering fluconazole is not indicated for RSV. Fluconazole is an antifungal medication, and RSV is a viral respiratory infection. Antifungal medications like fluconazole are not effective against viruses like RSV.
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