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 B

Explanation

A. To stay with the client's body for 8 hr following their death: While it is common for family members to stay with the deceased, the duration of time can vary and is not specifically aligned with Hindu customs.

B. To cremate the client's body: In Hinduism, cremation is the most common practice following death. The family is likely to request this as it aligns with religious beliefs and traditions.

C. To prohibit medical personnel from touching the client's body: In Hinduism, there is no blanket prohibition against medical personnel touching the body. However, some families may have specific requests for the handling of the body, but this is not universally expected.

D. To bury the client's body within 24 hr of their death: Hindus typically prefer cremation rather than burial. While burial is practiced in certain Hindu traditions, cremation is far more common, and the request for burial within 24 hours may not apply.

A. Report the incident to the charge nurse. B. Tell the staff members to stop their discussion. C. Participate in an in-service about client confidentiality. D. Speak to the staff members in private about client confidentiality.

Correct Answer is B

Explanation

A. Reporting the incident to the charge nurse is incorrect as the first step. While this action may be necessary if the issue continues, the immediate step should be to intervene directly to stop the conversation and prevent further breach of confidentiality.

B. Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client’s medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client’s privacy is respected.

C. Participating in an in-service about client confidentiality is incorrect as the first step. While in-service education on client confidentiality is important, it is not an immediate action to address a current breach of confidentiality.

D. Speaking to the staff members in private about client confidentiality is incorrect. While private conversation is important to address the issue further, the first action is to stop the conversation immediately to prevent any further privacy violations.

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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?

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Naxlex Comprehensive Predictor Exams

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