A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

i. Clean the puncture site with antiseptic and allow it to dry helps reduce the risk of infection and ensures an accurate reading by preventing contamination.

ii. Wipe away the first drop of blood before collecting the sample is the best next step because the first drop may contain tissue fluid, which can affect glucose accuracy.

Incorrect answers:

i

Warming the client's hand before performing the fingerstick improves blood flow, making it easier to obtain an adequate sample, especially in clients with diabetes who may have impaired circulation.

Massage the finger gently from the base toward the tip before puncturing promotes blood flow but should be done carefully to avoid excess squeezing, which can lead to inaccurate results.

ii

Ensure the client's hand is below heart level when obtaining the sample encourages blood flow, making collection easier.

Apply firm pressure to the site after obtaining the sample prevents excessive bleeding and helps close the puncture site.

A. "I should apply clean dressings over the top of blood-saturated dressings and hold pressure.” This prevents disruption of clot formation and controls bleeding.

B. "I can clean wounds with hydrogen peroxide.” Hydrogen peroxide can damage healthy tissue and delay healing.

C. "I can carefully remove the object from a penetrating wound.” Objects should be left in place until medical professionals remove them.

D. "I should place the affected area in a dependent position.” Elevating an injured limb helps reduce swelling and bleeding.