“A nurse is obtaining a 2-hr postprandial blood glucose from a patient. Which of the following actions should the nurse take?”

“Hold the finger above the heart prior to puncture.”.

“Smear the blood onto the reagent strip.”.

“Puncture the finger while still damp with antiseptic solution.”.

“Select the lateral side of the finger for puncture.”.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Holding the finger above the heart prior to puncture does not affect the accuracy of a blood glucose test.
Choice B rationale
Smearing the blood onto the reagent strip can result in inaccurate readings.
Choice C rationale
Puncturing the finger while still damp with antiseptic solution can cause discomfort and potentially contaminate the sample.
Choice D rationale
Selecting the lateral side of the finger for puncture is recommended because it is less painful and has good blood flow.

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Correct Answer is B

Explanation

Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.

A. Transient strabismus B. Mottling C. Respiratory rate of 70/min D. Loose stools E. Regurgitation

Correct Answer is C

Explanation

Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.

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“A nurse is obtaining a 2-hr postprandial blood glucose from a patient. Which of the following actions should the nurse take?”

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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