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 A
Explanation
Choice A: Reports of itching, tingling and pain in genital area are the correct answer because they are common symptoms of genital herpes. Genital herpes is a sexually transmitted infection (STI) caused by the herpes simplex virus (HSV). It can cause outbreaks of painful blisters or sores on or around the genitals, anus, or mouth. The blisters or sores usually heal within a few weeks, but the virus remains in the body and can reactivate at any time. Before an outbreak, some people may experience prodromal symptoms such as itching, tingling, or pain in the affected area.
Choice B: Painful urination with a penile discharge present is not the correct answer because it is more likely a symptom of another STI, such as gonorrhea or chlamydia. Gonorrhea and chlamydia are bacterial infections that can affect the urethra, cervix, rectum, or throat. They can cause symptoms such as burning or pain during urination, abnormal discharge from the penis or vagina, or bleeding between periods.
Choice C: Wart-like flesh-colored lesions on the scrotal area are not the correct answer because they are more likely a symptom of another STI, such as human papillomavirus (HPV). HPV is a viral infection that can cause genital warts or cervical cancer. Genital warts are small, soft, flesh-colored growths that can appear on or around the genitals, anus, or mouth. They may be flat, raised, or cauliflower-shaped.
Choice D: A chancre on the penis is not the correct answer because it is more likely a symptom of another STI, such as syphilis. Syphilis is a bacterial infection that can affect various organs and systems of the body. It has four stages: primary, secondary, latent, and tertiary. In the primary stage, syphilis causes a painless sore called a chancre that can appear on or around the genitals, anus, or mouth. The chancre usually heals within a few weeks, but the infection can progress to the next stages if left untreated.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Baby oil is not an acceptable lubricant, as it can damage the condom and reduce its effectiveness. The students should use water-based or silicone-based lubricants instead.
Choice B reason: Ensuring a tight fit of the condom is not advisable, as it can cause discomfort and increase the risk of breakage. The students should leave some space at the tip of the condom to collect semen and prevent spillage.
Choice C reason: Only using latex condoms is correct, as they are more effective than other materials in preventing pregnancy and sexually transmitted infections. The students should avoid using condoms made of natural skin or lambskin, as they are porous and can allow viruses to pass through.
Choice D reason: Placing the condom on an erect penis is correct, as it ensures proper application and prevents slippage. The students should unroll the condom over the entire length of the penis before any sexual contact.
Choice E reason: Storing the condoms in a cool dry place is correct, as it prevents exposure to heat, moisture, sunlight, or sharp objects that can damage the condom. The students should check the expiration date and integrity of the condom before use.
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