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 A
Explanation
Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.
When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.
The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.
Correct Answer is A
Explanation
Choice A Reason:
Planning to remove the restraints as soon as the client is calm is a correct action. Restraints should be used for the shortest duration necessary to ensure safety. Once the client is calm and no longer poses a risk to themselves or others, the restraints should be removed promptly.
Choice B Reason:
Ensuring that the provider has signed a prescription for restraints within 48 hr is incorrect. Restraints should never be applied without a proper prescription or order from a qualified healthcare provider. The provider's order should be obtained before applying restraints, not within 48 hours afterward.
Choice C Reason:
Offering the client, a nutritious snack every 4 hr is unrelated to the use of physical restraints and should not be the nurse's priority in this situation. The focus should be on ensuring the client's safety and addressing their behavior.
Choice D Reason:
Monitoring the client's range of motion every 60 min is a correct action. When a client is restrained, it's essential to monitor their physical well-being regularly. Monitoring range of motion helps ensure that the restraints are not causing harm or discomfort to the client. The specific time interval for monitoring may vary by facility policy but should be frequent enough to assess the client's condition effectively.
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