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 D

Explanation

A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.

B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.

C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.

D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.

A. Restrict protein intake by limiting meats and other high protein foods. B. Increase intake of high fiber foods, such as bran cereal. C. Limit oral fluid intake to 500 mL/day. D. Increase intake of potassium rich foods such as bananas or cantaloupe.

Correct Answer is A

Explanation

A. Restricting protein intake is often recommended for clients with glomerulonephritis to reduce the workload on the kidneys and decrease proteinuria. This can help slow the progression of kidney damage.

B. Increasing intake of high-fiber foods may be beneficial for overall health but is not specifically indicated for glomerulonephritis management.

C. Limiting oral fluid intake to 500 mL/day is not appropriate for most clients and may lead to dehydration, which can exacerbate kidney dysfunction.

D. Increasing intake of potassium-rich foods may be contraindicated in some cases of glomerulonephritis, especially if the client has hyperkalemia. Dietary potassium restriction may be necessary depending on the client's lab values and kidney function.

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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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Correct Answer is D

Explanation

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