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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. The WBC count assesses the number of white blood cells in the blood, which are key components of the immune system involved in fighting infection. An elevated WBC count (leukocytosis) may indicate an inflammatory response to infection, including bacterial colonization or superinfection of burn wounds.
A. The hematocrit measures the proportion of red blood cells in the blood and is used to evaluate for anemia or dehydration.
B. The platelet count measures the number of platelets in the blood and is used to assess for bleeding disorders or clotting abnormalities.
D. While changes in blood pH may occur in response to severe burn injuries, it is not typically the primary laboratory value assessed to determine the presence of infection.
Correct Answer is A
Explanation
A. Right-sided heart failure can lead to systemic venous congestion, resulting in symptoms such as pitting edema in the lower extremities and jugular venous distention. Increased central venous pressure is also characteristic of right-sided heart failure.
B. Left ventricular dysfunction typically presents with symptoms of pulmonary congestion, such as dyspnea, orthopnea, and crackles on lung auscultation. While left ventricular dysfunction can lead to right-sided heart failure over time, it is not typically associated with pitting edema of the lower extremities or jugular venous distention.
C. Cardiac tamponade is a medical emergency characterized by compression of the heart due to fluid accumulation in the pericardial sac, leading to impaired cardiac filling and hemodynamic compromise. While jugular venous distention may be present in cardiac tamponade due to elevated central venous pressure, pitting edema of the lower extremities is not a typical finding.
D. Internal bleeding may cause hypovolemia and hemodynamic instability, but it typically does not present with the specific findings of pitting edema of the lower extremities and jugular venous distention with increased central venous pressure.
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