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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 ["D","E"]

Explanation

Deep tendon reflexes (DTR):At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.

Heart rate:At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.

Other findings:

Urine output 40 mL in the last hour:Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.

Temperature 38.3°C (101°F):This indicates a fever, which is not a sign of improvement.

Blood pressure 146/96 mm Hg:Although this is better than a severely hypertensive reading, it is still elevated.

A. Maintain bed rest for 48 hr. B. Keep legs in a dependent position. C. Wrap the leg with an elastic bandage. D. Implement a sodium-restricted diet.

Correct Answer is C

Explanation

The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.

The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.

The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.

The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.

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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?

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Correct Answer is ["D","E"]

Explanation

Other findings:

A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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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?