A nurse is preparing to measure a post-meal blood glucose level in a patient with diabetes mellitus. What steps should the nurse take?

Prick the central tip of the patient’s finger.

Apply the first drop of blood to the test strip.

Hold the patient’s finger in a dependent position.

Clean the patient’s finger with hexachlorophene.

Answer and Explanation

The Correct Answer is C

A. Prick the central tip of the patient’s finger: The central tip of the finger has more nerve endings, making it more painful. Instead, the side of the fingertip should be used because it has fewer nerve endings and promotes better blood flow.

B. Apply the first drop of blood to the test strip: The first drop of blood may contain interstitial fluid or contaminants (e.g., alcohol residue), leading to inaccurate readings. Instead, the first drop should be wiped away, and the second drop should be used for testing.

C. Hold the patient’s finger in a dependent position: Holding the finger in a dependent position (below heart level) helps increase blood flow to the fingertip, making it easier to obtain an adequate blood sample without excessive squeezing, which could dilute the sample with tissue fluid.

D. Clean the patient’s finger with hexachlorophene: Hexachlorophene is not recommended for skin antisepsis before blood glucose testing. Instead, alcohol wipes or soap and water should be used. The finger should be fully dried before pricking to avoid dilution of the blood sample.

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Correct Answer is A

Explanation

Comparing the current blood pressure reading to the preoperative value is the first step the nurse should take. This will help determine if the patient’s blood pressure has significantly dropped, which could indicate hypovolemia or shock.

Choice B rationale

Covering the patient with a warm blanket may be helpful if the patient is feeling cold or showing signs of hypothermia, but it would not address the underlying cause of the low blood pressure.

Choice C rationale

Increasing the IV flow rate might be necessary if the patient is hypovolemic, but this decision should be based on additional assessment data and physician orders.

Choice D rationale

Reassuring the patient is important, but it should not be the first action. The nurse needs to assess and address the cause of the low blood pressure.

A. Administering IV fluids with a potassium supplement. B. Administering pain medication. C. Inserting a nasogastric tube. D. Requesting a prescription for an antiemetic.

Correct Answer is A

Explanation

Choice A rationale

When a patient is initiating IV therapy, one of the tasks a nurse may perform is administering IV fluids with a potassium supplement. This is a common task in IV therapy. Therefore, this choice is correct.

Choice B rationale

Administering pain medication could be a part of a nurse’s responsibilities, but it is not specific to the initiation of IV therapy. Therefore, this choice is incorrect.

Choice C rationale

Inserting a nasogastric tube is not a task associated with initiating IV therapy. Therefore, this choice is incorrect.

Choice D rationale

Requesting a prescription for an antiemetic is not a task associated with initiating IV therapy. Therefore, this choice is incorrect.

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A nurse is preparing to measure a post-meal blood glucose level in a patient with diabetes mellitus. What steps should the nurse take?

Nursing Test Bank

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