A nurse is performing a capillary blood glucose test on a client. Which of the following actions should the nurse take?
Don sterile gloves prior to the procedure.
Hold the finger in an upright position prior to the procedure.
Use the lateral tip of the finger to obtain specimen.
Discard the lancet in the trash container.
The Correct Answer is C
Rationale:
A. Don sterile gloves prior to the procedure: Clean gloves, not sterile gloves, are required for a capillary blood glucose test since it is a clean, not sterile, procedure. Sterile technique is unnecessary and not cost-effective for this type of routine testing.
B. Hold the finger in an upright position prior to the procedure: The finger should be held in a dependent (downward) position to promote blood flow to the puncture site. Holding it upright may reduce perfusion and make obtaining an adequate sample more difficult.
C. Use the lateral tip of the finger to obtain specimen: The lateral sides of the fingertip have fewer nerve endings than the center and are more vascular, making them ideal for obtaining an adequate blood sample with minimal discomfort to the client.
D. Discard the lancet in the trash container: Lancets are sharp instruments and must be discarded in an approved sharps container to prevent needle-stick injuries and ensure proper infection control. Disposing of them in regular trash poses a safety hazard.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.
B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.
C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.
D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.
Correct Answer is B
Explanation
Rationale:
A. Eat foods high in vitamin B: Although B-vitamin deficiencies can contribute to stomatitis, eating foods high in vitamin B may not immediately relieve symptoms. Nutritional support is important long-term, but bland food recommendations provide immediate comfort.
B. Consume soft, bland foods: Soft, bland foods reduce mechanical and chemical irritation to the oral mucosa, promoting healing and reducing discomfort. These are ideal dietary choices for clients with stomatitis.
C. Rinse the mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can worsen irritation and dryness of the oral mucosa, aggravating stomatitis symptoms. Alcohol-free rinses or saline solutions are better alternatives.
D. Use lemon glycerin swabs: Lemon glycerin swabs can cause further drying and irritation of the mucosa. They are not recommended for clients with stomatitis, as they may intensify pain and inflammation.
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