A nurse is obtaining a capillary blood specimen to measure a client's blood glucose. Which of the following actions should the nurse take?

Allow the antiseptic to dry before puncturing.

Apply sterile gloves.

Hold the lancet at a 45° angle.

Massage the client's finger away from the puncture site.

Answer and Explanation

The Correct Answer is A

A. Allow the antiseptic to dry before puncturing.: This is correct. It is important to allow the antiseptic (such as alcohol) to dry before puncturing the skin. If the antiseptic is not allowed to dry, it can cause hemolysis of the blood sample and lead to inaccurate glucose readings.

B. Apply sterile gloves.: This is incorrect. While gloves should be worn to maintain hygiene and safety, non-sterile gloves are sufficient for a capillary blood glucose test. Sterile gloves are not necessary unless the procedure requires aseptic technique.

C. Hold the lancet at a 45° angle.: This is incorrect. The lancet should be held at a 90° angle to the skin to ensure a proper and clean puncture.

D. Massage the client's finger away from the puncture site.: This is incorrect. The finger should not be massaged before or after the puncture site because it can cause tissue damage and lead to inaccurate blood samples due to the mixing of interstitial fluid with the blood sample.

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Correct Answer is A

Explanation

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." This is the correct choice. The nurse should document the client's own account of the event in the medical record. It is important to accurately record the client's statement, as documentation should reflect the facts and avoid interpretation or assumptions.

B. "An incident report has been completed and sent to risk management." This statement should not be included in the client's medical record. Incident reports are separate from clinical documentation and are not part of the patient's permanent medical record.

C. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement makes an assumption about the cause of the fall and includes blame, which is inappropriate for medical documentation. Documentation should focus on objective observations and the client's statement, not assigning fault.

D. "The client does not appear to have any injuries resulting from the fall." While the nurse may assess the client for injuries, this statement should not be included unless it is confirmed and part of a thorough, objective assessment. It’s important to document specific findings (e.g., "No visible injuries noted").

A. Tachycardia B. Hypotension C. Neck pain D. Respiratory depression

Correct Answer is A

Explanation

A. Tachycardia: This is correct. Tachycardia is one of the hallmark signs of thyroid storm, a life-threatening complication of hyperthyroidism (often seen in Graves' disease.. The excessive thyroid hormone leads to severe metabolic disturbances, including an increased heart rate.

B. Hypotension: Hypotension is not typically a feature of thyroid storm. In fact, thyroid storm is more commonly associated with hypertension due to the increased heart rate and metabolic activity.

C. Neck pain: Neck pain is not a common symptom of thyroid storm. Neck pain might be related to other conditions, such as thyroiditis or a goiter, but not specifically thyroid storm.

D. Respiratory depression: Respiratory depression is not a typical symptom of thyroid storm. On the contrary, thyroid storm often leads to symptoms like hyperventilation, not depressed breathing.

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A nurse is obtaining a capillary blood specimen to measure a client's blood glucose. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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