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 A
Explanation
A. A negative pressure room is correct. Varicella zoster, which causes chickenpox, is an airborne virus. Therefore, airborne precautions are required, which include placing the client in a negative pressure room to prevent the spread of the virus to other areas of the facility.
B. Administering aspirin is incorrect. Aspirin should not be given to children or adolescents with varicella zoster due to the risk of Reye's syndrome. Instead, an antipyretic such as acetaminophen should be used to treat fever.
C. Contact precautions are not sufficient for varicella zoster, as the virus requires airborne precautions to prevent transmission through the air.
D. Having visitors remain at least 0.91 m (3 feet) away is incorrect. Airborne precautions require that visitors wear appropriate PPE, including respirators, and should not be restricted to 3 feet away. Ideally, visitors should wear full protective gear when entering the room.
Correct Answer is C
Explanation
A. "Eat 40 milligrams of protein-rich foods per day.": Protein intake is important during pregnancy, but 40 milligrams is an unusually low amount. The recommended amount is generally higher, around 71 grams of protein per day during pregnancy.
B. "Increase your dietary intake by 500 calories per day.": The general recommendation for calorie increase during pregnancy is about 300 calories per day, not 500. 500 calories per day may be recommended in specific situations, but it is not the typical guideline.
C. "Consume 600 micrograms of folic acid per day.": This is the correct recommendation. The CDC and other health guidelines recommend that pregnant individuals consume 400-600 micrograms of folic acid daily to prevent neural tube defects.
D. "Limit your caffeine intake to 700 milligrams per day.": Caffeine intake should generally be limited to around 200-300 milligrams per day during pregnancy, not 700 milligrams, as high caffeine intake can have adverse effects on pregnancy outcomes.
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