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 B

Explanation

B Restricting protein intake can help reduce the workload on the kidneys and minimize proteinuria (excess protein in the urine), which is common in glomerulonephritis. Limiting high-

protein foods, especially animal proteins, can help slow the progression of kidney damage and preserve kidney function.
A Increasing potassium intake is generally not recommended in glomerulonephritis, especially if the client has hyperkalemia (elevated potassium levels). In kidney disease, potassium levels can become elevated due to decreased excretion by the kidneys.
C Limiting oral fluid intake to 500 mL/day is not a suitable recommendation for most clients with glomerulonephritis. Adequate hydration is important for maintaining kidney function and preventing complications such as dehydration and electrolyte imbalances.
D While increasing fiber intake is generally beneficial for overall health and gastrointestinal function, it is not a specific dietary recommendation for clients with glomerulonephritis.

A. Increased temperature to lower extremity. B. Circumferential edema of right foot. C. Right foot pale with sluggish capillary refill. D. Reports throbbing right leg pain.

Correct Answer is C

Explanation

C. A pale right foot with sluggish capillary refill suggests compromised blood flow to the foot, which may indicate arterial insufficiency or compartment syndrome. Compromised circulation can lead to tissue ischemia and necrosis if not promptly addressed.
A. While increased temperature to the lower extremity may indicate inflammation or infection, it is not as urgent as the finding of compromised circulation.
B. Circumferential edema of the right foot may occur due to trauma or inflammation and can contribute to increased pressure within the leg compartment, potentially leading to compartment syndrome. While edema should be monitored closely, the finding of pale color and sluggish capillary refill is more indicative of compromised circulation and requires immediate intervention.
D. Throbbing right leg pain is a common symptom following a fracture and cast application and may be managed with pain medication. While it should be addressed, it is not as urgent.

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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

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