The nurse has reviewed the Nurses' Notes and Vital Signs at 1200.

Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?

A. Plan time at the end of the shift to document nursing interventions: Waiting until the end of the shift to document can lead to inaccuracies and missed details. It is more effective to document in real-time or immediately after providing care to ensure complete, accurate, and timely records, reducing errors and memory lapses.

B. Keep track of how long it takes to complete certain tasks: Monitoring how long tasks take helps the nurse better allocate time and identify where delays occur. This awareness allows for improved scheduling, more accurate prioritization, and realistic planning during the shift, leading to better time management.

C. Delegate collection of vital signs to the assistive personnel on the team: Delegating appropriate tasks, like vital signs collection, frees the nurse to focus on critical thinking, assessments, and interventions that require professional judgment. Proper delegation is an essential time-management strategy in providing efficient and safe client care.

D. Complete activities with one client before moving to another client: While thoroughness is important, it is not always efficient to rigidly finish all activities with one client before seeing others. Time-sensitive or urgent tasks with other clients may require interruptions, and flexibility is crucial for safe, effective care management.

E. Make a priority to do it at the beginning of the shift: Establishing priorities at the beginning of the shift ensures that essential and urgent needs are addressed promptly. Early planning helps organize tasks efficiently, reduces chaos during busy periods, and helps maintain focus throughout the shift.

A. Position the client's finger above their heart: The finger should be positioned below the level of the heart to encourage blood flow, making it easier to obtain a sufficient blood sample for testing. Elevating the finger would decrease blood flow and make collection more difficult.

B. Apply sterile gloves prior to performing the test: Clean, non-sterile gloves are sufficient for routine blood glucose monitoring. Sterile gloves are not necessary unless performing procedures that require a sterile environment, such as surgery or central line dressing changes.

C. Puncture the side of the client's finger: The sides of the fingertips have fewer nerve endings compared to the pads, making the procedure less painful. Additionally, puncturing the side helps promote better blood flow and reduces the risk of bruising and soreness.

D. Milk the finger site: Milking or squeezing the finger excessively can cause hemolysis or contamination of the blood sample with tissue fluid, leading to inaccurate glucose readings. Gentle pressure may be used if needed, but forceful milking should be avoided.