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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Internal bleeding may present with symptoms such as hypotension, tachycardia, and signs of blood loss, but it typically does not cause pitting edema or jugular venous distention.
B. Right-sided heart failure can cause systemic venous congestion, leading to pitting edema of the lower extremities and jugular venous distention due to increased central venous pressure.
C. Cardiac tamponade presents with Beck's triad (hypotension, distended neck veins, muffled heart sounds) and is typically more acute in onset compared to the gradual development of symptoms seen in right-sided heart failure.
D. Left ventricular dysfunction primarily causes symptoms of pulmonary congestion, such as dyspnea, orthopnea, and crackles, rather than pitting edema and jugular venous distention.
Correct Answer is D
Explanation
A. Assessing for increasing fluid volume overload is not indicated with a rising serum sodium level; instead, it suggests correction of hyponatremia, a common complication of SIADH.
B. Withholding the next scheduled dose of treatment is not appropriate based solely on a rise in serum sodium level within the normal range.
C. Increasing neurologic checks may be necessary in severe cases of hyponatremia but is not directly indicated by a rise in serum sodium within the normal range.
D. Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.
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