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 D

Explanation

D Peritoneal dialysis involves using the peritoneum (the lining of the abdominal cavity) as a semipermeable membrane to remove waste products and excess fluid from the body. It requires a healthy peritoneal membrane for effective dialysis. Crohn's disease, especially if it has led to extensive inflammation or scarring of the peritoneum, can impair the function of the peritoneum and make peritoneal dialysis less effective or even contraindicated.
A While chronic viral hepatitis may affect the liver's ability to metabolize waste products, it is not necessarily a contraindication for peritoneal dialysis. However, active hepatitis or significant liver dysfunction may impact the choice of dialysis modality and require careful evaluation by the healthcare team.
B Nephrotic syndrome involves kidney damage that leads to excessive protein loss in the urine, fluid retention, and other complications. While nephrotic syndrome may necessitate dialysis as kidney function declines, it is not a contraindication for peritoneal dialysis per se.
C While diabetes-related complications can influence the choice of dialysis modality and require close monitoring, type 2 diabetes mellitus alone is not a contraindication for peritoneal dialysis.

A. Administer medications as ordered. B. Provide client teaching. C. Place the client in Trendelenburg position D. Ask the client for a list of current medications. E. Notify the healthcare provider of the client's need for intubation F. Apply oxygen via nasal cannula

Correct Answer is ["A","B","D","F"]

Explanation

A The use of short acting beta agonists and oral steroids is key during an asthmatic attack to prevent respiratory failure.
D The nurse should also rule out the use of medications such as beta blockers which may predispose to asthmatic attack due to bronchospasms.
F Oxygen therapy should be initiated to prevent hypoxemia due to impaired ventilation. At this point, intubation may not be necessary until first line interventions have been attempted.
B Client teaching on proper inhalation technique is key. The client should also be advised on avoidance of triggers to prevent recurrence of the asthmatic attack. This, however, should be done after the client is stabilized.

Incorrect;

The Trendelenburg position is not recommended. Instead, sitting upright or in a semi-upright position can help expand the chest and improve lung expansion. This position allows the diaphragm to move more freely and can facilitate easier breathing. Leaning forward slightly may also help reduce the feeling of chest tightness.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

Correct Answer is D

Explanation

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.

Correct Answer is ["A","B","D","F"]

Explanation

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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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