A laboratory technician arrives to draw blood for a complete blood count (CBC) for a client who had a right-sided mastectomy 8 hours ago. The client has an intravenous line with fluid infusing in her left antecubital space. To obtain the blood specimen, the technician places a tourniquet on the client's right arm. Which action by the nurse would be most appropriate?
Call the surgeon to perform a femoral puncture.
Assist in holding the client's arm still.
Tell the technician to obtain the blood sample from the client's left arm.
Suggest a finger stick be done on one of the client's left fingers.
The Correct Answer is C
Choice A: Call the surgeon to perform a femoral puncture. This action is not appropriate because it is unnecessary and invasive. A femoral puncture is a procedure that involves inserting a needle into the femoral vein in the groin area to obtain a blood sample. It is usually reserved for situations where other veins are inaccessible or unsuitable, such as in trauma or shock. It is not indicated for a routine CBC test.
Choice B: Assist in holding the client's arm still. This action is not appropriate because it is harmful and contraindicated. Holding the client's arm still may cause injury or infection to the arm that has undergone surgery and lymph node removal. It may also increase the risk of lymphedema, which is a condition that causes swelling and pain in the arm due to fluid accumulation and impaired lymphatic drainage.
Choice C: Tell the technician to obtain the blood sample from the client's left arm. This action is appropriate because it is safe and recommended. Obtaining the blood sample from the client's left arm can avoid complications such as injury, infection, or lymphedema in the right arm that has undergone surgery and lymph node removal. The technician can use a different site than the antecubital space, such as the hand or wrist, to avoid interfering with the intravenous line.
Choice D: Suggest a finger stick be done on one of the client's left fingers. This action is not appropriate because it is unreliable and inaccurate. A finger stick is a procedure that involves pricking the finger with a lancet to obtain a small amount of blood for testing. It is usually used for point-of-care testing, such as glucose or hemoglobin levels, but not for a CBC test. A CBC test requires a larger volume of blood and a venous sample for accurate results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Trichomoniasis is not the correct answer because it does not match the findings of the client. Trichomoniasis is a sexually transmitted infection (STI) caused by a parasite called Trichomonas vaginalis. It can cause symptoms such as yellow-green or gray frothy vaginal discharge, foul odor, itching, burning, or redness of the vulva or vagina.
Choice B: Genital herpes simplex is not the correct answer because it does not match the findings of the client. Genital herpes simplex is an STI caused by a virus called herpes simplex virus (HSV). It can cause symptoms such as painful blisters or ulcers on or around the genitals, fever, headache, or swollen lymph nodes.
Choice C: Candidiasis is the correct answer because it matches the findings of the client. Candidiasis is a fungal infection caused by a yeast called Candida albicans. It can cause symptoms such as thick, white, cottage cheese-like vaginal discharge, intense itching, burning, or soreness of the vulva or vagina, or dyspareunia (painful sexual intercourse).
Choice D: Bacterial vaginosis is not the correct answer because it does not match the findings of the client. Bacterial vaginosis is a condition caused by an imbalance of the normal vaginal flora (the bacteria that live in the vagina). It can cause symptoms such as thin, gray-white or yellow vaginal discharge, fishy odor, itching, or burning of the vulva or vagina.
Correct Answer is D
Explanation
Choice A reason: Brushing teeth does not require much strength or range of motion in the hand, so it should not be very difficult for the client.
Choice B reason: Buttoning a blouse can be done with one hand or with the help of the other hand, so it should not be very difficult for the client.
Choice C reason: Eating breakfast can be done with the left hand or with utensils that are easy to hold, so it should not be very difficult for the client.
Choice D reason: Combing hair requires lifting the arm above the shoulder and moving the hand through the hair, which can be painful and challenging for the client who had a mastectomy and may have impaired lymphatic drainage and nerve damage in the right arm.
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