A nurse is collecting a capillary blood sample from an older adult client. After puncturing the client's finger, the nurse is unable to obtain an adequate amount of blood. Which of the following actions should the nurse take?
Rub the puncture site with an alcohol pad.
Apply firm pressure to the puncture site.
Wrap the client's hand in a warm washcloth.
Have the client raise his hand.
The Correct Answer is C
Choice A Reason:
Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.
Choice B Reason:
Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.
Choice C Reason:
Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.
Choice D Reason:
Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A client can withdraw consent at any time is appropriate. This statement is accurate. Informed consent is a voluntary process, and a client has the right to withdraw their consent at any point before or during a medical procedure.
Choice B Reason:
A family member should witness the client's consent is not a standard practice. Typically, a witness is someone who is neutral and not directly involved in the procedure.
Choice C Reason:
A nurse is responsible for obtaining informed consent is not entirely accurate. While nurses may provide information and answer questions, obtaining informed consent is typically the responsibility of the healthcare provider performing the procedure.
Choice D Reason:
A minor who is pregnant is unable to give consent is not a universally true statement. The ability of a minor to give consent can vary based on legal and ethical considerations, and it may depend on local laws and regulations.
Correct Answer is C
Explanation
Choice A Reason:
"Opioids will be restricted if your partner develops respiratory distress." This statement might cause unnecessary concern or confusion. While opioid use might be adjusted based on the client's condition and symptoms, framing it in terms of restriction might not be the most appropriate way to communicate about pain management in end-of-life care.
Choice B Reason:
"Encourage your partner to eat three large meals each day." Encouraging large meals might not align with the typical dietary approach for someone in end-of-life care, especially if they have reduced appetite or are unable to eat comfortably. End-of-life care often focuses on providing smaller, more manageable meals based on the individual's preferences and capabilities.
Choice C Reason:
"Assume your partner can hear you, even if they do not respond. “This statement encourages the partner to communicate with their loved one, acknowledging the potential for the person to hear even if they are not responsive. Many studies suggest that hearing may persist even in individuals who are unresponsive or in a comatose state, so speaking to them can provide comfort and connection.
Choice D Reason:
"We will use an electric blanket to keep your partner warm." The use of an electric blanket might not be suitable, as the client's sensitivity to temperature might change in end-of-life care. Other methods, such as blankets or adjusting the room temperature, could be more appropriate to ensure comfort without the risks associated with electric blankets.
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