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?

Collect the blood sample.

Select another finger.

Apply pressure to the site.

Assess radial pulse volume.

Answer and Explanation

The Correct Answer is B

A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.

B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.

C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.

D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.

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Correct Answer is B

Explanation

A. Administer IV fluid bolus as prescribed by the healthcare provider is not the priority unless there is evidence of hypovolemia or shock, which isn't indicated by the current vital signs alone.

B. Medicate for pain and monitor vital signs according to protocol is the most important intervention. The client's elevated heart rate, respiratory rate, and blood pressure are likely due to inadequate pain control following a thoracotomy, a major surgical procedure known for causing significant postoperative pain. Managing the pain is crucial because uncontrolled pain can lead to increased sympathetic nervous system activity, resulting in tachycardia, hypertension, and tachypnea. Addressing the pain effectively will help stabilize these vital signs.

C. Encourage the client to splint the incision with a pillow to cough and deep breathe is an important postoperative intervention to prevent complications such as atelectasis, but it should be done after pain is adequately controlled, as pain can inhibit the ability to deep breathe and cough effectively.

D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter may be necessary if there are signs of hypoxia. However, the vital sign changes here are more likely related to pain rather than respiratory distress, making pain management the immediate priority.

A. Methotrexate slows the disease progression while aspirin controls the symptoms. B. Methotrexate helps to reduce the side effects of the aspirin therapy. C. Methotrexate enhances the effectiveness of the aspirin. D. Methotrexate has less harmful side effects than aspirin.

Correct Answer is A

Explanation

A. Methotrexate is commonly used in the treatment of rheumatoid arthritis (RA) to slow the progression of the disease by suppressing the immune system's response that causes inflammation. Aspirin may be used concurrently to provide symptomatic relief from pain and inflammation associated with RA.
B. While methotrexate may have side effects, its primary indication in RA treatment is to slow disease progression rather than to mitigate aspirin side effects.
C. Methotrexate and aspirin typically work through different mechanisms of action and are not typically used together to enhance each other's effectiveness.
D. Methotrexate and aspirin have different side effect profiles, but the primary reason for adding methotrexate is to slow the progression of RA rather than to replace aspirin due to side effects.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?

Correct Answer is A

Explanation

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