The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Select another finger.

Assess radial pulse volume.

Collect the blood sample.

Apply pressure to the site.

Answer and Explanation

The Correct Answer is D

D. Applying pressure to the site helps to reduce engorgement and promote normal blood flow. This action can help alleviate the localized congestion and ensure a more accurate fingerstick glucose measurement. Once the pressure is applied and the congestion subsides, the nurse can proceed with collecting the blood sample.
A. While selecting another finger may be considered if the initial fingerstick attempt was unsuccessful or if the fingertip is excessively traumatized, it may not be necessary if the observation of redness and engorgement can be addressed with appropriate pressure application to the site.
B. Assessing radial pulse volume is not directly relevant to addressing the observed redness and engorgement of the fingertip after milking. This action is more appropriate for evaluating peripheral circulation and arterial perfusion in other clinical contexts
C. Collecting the blood sample without addressing the observed redness and engorgement of the fingertip may result in a suboptimal sample quality and could cause discomfort or further tissue trauma to the client.

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Correct Answer is ["A"]

Explanation

Subjective data refers to the symptoms reported by the client while objective data refers to the information collected on assessment of the client. During asthmatic attack, the client reports of shortness of breath, audible wheezing, inability to speak in complete sentences and a feeling of nervousness.

The use of a reliever without relief during an asthmatic attack indicates the severity of the attack. This requires intervention including the introduction of inhaled corticosteroids to reduce airway inflammation and remodeling.

The recurrence of symptoms on exposure to exercise requires the need for further advise to avoid triggers and recurrence of symptoms.

A. Inappropriate laughter. B. Asymmetrical weakness. C. Increasing anxiety. D. Weakened cough effort.

Correct Answer is D

Explanation

Weakened cough effort can lead to ineffective airway clearance and increase the risk of aspiration pneumonia, a common complication in ALS due to bulbar muscle involvement. Aspiration pneumonia is a serious and potentially life-threatening condition that requires immediate intervention
A This symptom can be distressing for the client and may impact their quality of life. While it should be addressed and managed, it does not pose an immediate threat to the client's physical health.
B Asymmetrical weakness is a hallmark feature of ALS, where muscle weakness typically begins in one region of the body and gradually spreads to other areas. While it signifies disease progression and may impact the client's mobility and function, it does not necessarily require immediate intervention.
C Anxiety is a common emotional response in clients with ALS, especially as the disease progresses and the client faces physical decline and uncertainty about the future. While it is important to address the client's emotional well-being and provide support, increasing anxiety does not usually warrant immediate intervention.

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The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

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Correct Answer is ["A"]

Explanation

While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is D

Explanation

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

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