A nurse is performing blood glucose monitoring on a client. Which of the following actions should the nurse take?
Position the client's finger above their heart.
Apply sterile gloves prior to performing the test.
Puncture the side of the client's finger.
Milk the finger site.
The Correct Answer is C
A. Position the client's finger above their heart: The finger should be positioned below the level of the heart to encourage blood flow, making it easier to obtain a sufficient blood sample for testing. Elevating the finger would decrease blood flow and make collection more difficult.
B. Apply sterile gloves prior to performing the test: Clean, non-sterile gloves are sufficient for routine blood glucose monitoring. Sterile gloves are not necessary unless performing procedures that require a sterile environment, such as surgery or central line dressing changes.
C. Puncture the side of the client's finger: The sides of the fingertips have fewer nerve endings compared to the pads, making the procedure less painful. Additionally, puncturing the side helps promote better blood flow and reduces the risk of bruising and soreness.
D. Milk the finger site: Milking or squeezing the finger excessively can cause hemolysis or contamination of the blood sample with tissue fluid, leading to inaccurate glucose readings. Gentle pressure may be used if needed, but forceful milking should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hyperglycemia: Albuterol is not prescribed to manage blood glucose levels. While it can sometimes cause a mild increase in blood glucose as a side effect, its primary therapeutic action is not directed at treating hyperglycemia or any diabetic conditions.
B. Swelling of the lips: Swelling of the lips could indicate an allergic reaction or angioedema, which is a medical emergency. Albuterol is not used to treat allergic swelling; epinephrine would be the medication of choice in managing severe allergic reactions or anaphylaxis.
C. Nausea: Albuterol is not intended to treat nausea. Although gastrointestinal upset, including nausea, can sometimes occur as a side effect of albuterol, it is not administered for the purpose of controlling nausea in clients.
D. Shortness of breath: Albuterol is a short-acting beta2-agonist that works by relaxing bronchial smooth muscle, leading to bronchodilation. It is commonly prescribed to relieve acute episodes of shortness of breath, wheezing, or bronchospasm, particularly in asthma or COPD.
Correct Answer is D
Explanation
A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6°C (99.7°F): A mild temperature in the context of periorbital cellulitis is expected and not an immediate emergency. Although periorbital cellulitis can be serious, this temperature alone does not demand immediate action over other critical symptoms.
B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10: A headache with influenza is common and requires monitoring, but unless there are signs of severe neurological involvement, it is not the highest priority compared to potential circulatory compromise.
C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding: Mild vomiting or spitting up is common following a pyloromyotomy and is not unusual within the first 24 hours postoperatively. It generally does not require immediate intervention unless persistent or worsening.
D. A child who had a cast placed 4 hr ago and reports numbness in the affected extremity: Numbness may indicate impaired circulation or nerve compression, a sign of possible compartment syndrome. This is a surgical emergency that can result in permanent damage if not promptly assessed and treated.
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