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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "It takes 2 months of scheduled use before this medication is effective." is incorrect. Montelukast is generally effective within 1-2 weeks of starting the medication, not 2 months.
B. "I will give this medication to my child once daily in the evening." is correct. Montelukast is usually administered once daily, in the evening, to help prevent asthma symptoms.
C. "I can stop giving my child this medication if he is taking a steroid." is incorrect. Montelukast and steroids can be used together to manage asthma, but stopping montelukast is not recommended unless advised by the healthcare provider.
D. "I will give this medication to my child every 2 hours if he is wheezing." is incorrect. Montelukast is a maintenance medication and should not be used as a rescue treatment for acute wheezing. For acute symptoms, a short-acting bronchodilator is typically used.
Correct Answer is D
Explanation
A. Tell the client she should discuss this decision with her family.: This is incorrect. While family involvement can be important in decisions regarding treatment, the nurse should respect the client's autonomy and support their right to make decisions about their own care.
B. Discuss alternative treatment methods with the client.: This is incorrect. Since the client has already made the decision to stop dialysis, the nurse should not push alternative treatment methods. The focus should be on supporting the client’s decision rather than presenting options they have chosen not to pursue.
C. Ask the facility chaplain to visit the client.: While a chaplain may provide valuable spiritual support, this is not the first action the nurse should take. It is more important to first support the client’s decision and ensure they are informed about the consequences.
D. Support the client's decision to stop the treatment.: This is correct. The nurse should support the client’s decision and provide care that aligns with the client’s values and wishes. It’s important to respect the client's right to make informed choices about their care, including the decision to discontinue dialysis.
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