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A nurse is using a glucometer to measure a client's capillary blood glucose level.

Which of the following actions should the nurse take?

Keep the finger in a dependent position.

Wear sterile gloves.

Select the central tip of a finger

Test the first drop of blood that forms after the puncture.

Answer and Explanation

The Correct Answer is A

A. Keep the finger in a dependent position:

Keeping the finger in a dependent position (lower than the heart) helps promote blood flow to the fingertips, making it easier to obtain a blood sample. This position can facilitate the formation of a blood drop, improving the chances of obtaining an adequate sample for testing.

B. Wear sterile gloves:

Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. Clean, non-sterile gloves are generally sufficient for this procedure. However, the nurse should perform proper hand hygiene to minimize the risk of contamination.

C. Select the central tip of a finger:

The central tip of the finger is more sensitive, and choosing this area may cause greater discomfort for the client. The sides of the fingertips are often preferred for capillary blood glucose testing as they have a good blood supply and are less sensitive.

D. Test the first drop of blood that forms after the puncture:

The initial drop may contain tissue fluid or contaminants from the puncture site, so it is important to use the first drop to obtain a representative blood sample. This step contributes to the accuracy of the blood glucose measurement.

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Correct Answer is B

Explanation

Answer: B. Client isolates themselves from their family and friends

Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.

A. Instruct the client to cough every 4 hr. B. Encourage the client to ambulate to loosen secretions. C. Maintain the client in high-Fowler's position. D. Increase the client's intake of oral fluids.

Correct Answer is C

Explanation

The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart.

This can help alleviate dyspnea and improve oxygenation in clients with heart failure.

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A nurse is using a glucometer to measure a client's capillary blood glucose level.

Which of the following actions should the nurse take?