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 A random plasma glucose level of 200 mg/dL (11.1 mmol/L) is indicative of hyperglycemia and suggests possible diabetes mellitus. This finding is significant and should be reported promptly to the healthcare provider for further evaluation and management.
D Hemoglobin A1C (HbA1C) is a measure of average blood glucose levels over the past 2-3 months. A level of 7% indicates poorly controlled diabetes, as the target for most individuals with diabetes is less than 7%. This finding suggests inadequate glycemic control and requires attention from the healthcare provider for adjustment of treatment regimen.
A While total cholesterol levels are important for assessing cardiovascular risk, a value of 180 mg/dL is within the desirable range (less than 200 mg/dL) and is not directly related to the symptoms reported by the client.
B Hematocrit levels within the reference range do not directly relate to the symptoms reported by the client and are not indicative of the underlying cause of frequent urination, hunger, and great thirst.
E While serum potassium levels are important for assessing electrolyte balance, a value of 4.2 mEq/L is within the normal reference range (3.5 to 5 mEq/L) and is not directly related to the symptoms reported by the client.
Correct Answer is D
Explanation
D. Platelets are responsible for primary hemostasis, which involves the initial formation of blood clots to stop bleeding. A low platelet count (thrombocytopenia) or dysfunction in platelet function can lead to bleeding manifestations such as petechiae and ecchymosis.
A. Hemoglobin levels measure the concentration of hemoglobin in the blood and are used to assess for anemia.
B. White blood cell count measures the number of white blood cells in the blood and is used to assess for infections or inflammatory conditions.
C Red blood cell count measures the number of red blood cells in the blood and is used to assess for anemia or erythrocytosis.
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