A nurse is preparing to obtain a blood sample from an adult client for a capillary blood glucose test. Which of the following sites should the nurse select?

The pad of the thumb

The pinna of the ear

The pad of the big toe

The side of the ring finger

Answer and Explanation

The Correct Answer is D

Choice A Reason:

The pad of the thumb is not typically recommended for capillary blood glucose testing. While it is possible to obtain a blood sample from the thumb, it is less commonly used due to the thickness of the skin and the presence of more nerve endings, which can make the procedure more painful. Fingertips, especially the sides of the fingers, are preferred because they have a rich supply of capillaries and are less painful.

Choice B Reason:

The pinna of the ear is not a standard site for capillary blood glucose testing. This area is not commonly used because it is less accessible and may not provide a reliable blood sample. The fingertips are more practical and provide consistent results due to their capillary density.

Choice C Reason:

The pad of the big toe is also not a common site for capillary blood glucose testing. Similar to the thumb, the skin on the toes is thicker and may be more painful to puncture. Additionally, the toes are less convenient and hygienic for frequent testing compared to the fingers.

Choice D Reason:

The side of the ring finger is one of the most recommended sites for capillary blood glucose testing. This area is preferred because it has a good capillary supply, making it easier to obtain an adequate blood sample. Additionally, the sides of the fingers are less sensitive than the pads, reducing discomfort during the procedure. Using the sides of the fingers also helps to avoid the more sensitive central part of the fingertip.

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Correct Answer is C

Explanation

Choice A Reason:

Changing the dressing four times per day is excessive and not typically recommended. Most guidelines suggest changing the dressing once a day or as needed if it becomes soiled or wet. Over-frequent dressing changes can disrupt the healing process and increase the risk of infection.

Choice B Reason:

Applying tincture of benzoin prior to removing the dressing is not a standard practice for wound care. Tincture of benzoin is usually used to increase the adhesion of bandages or tapes, not for removing dressings. Using it inappropriately could cause skin irritation or damage.

Choice C Reason:

Cleaning from the incision to the surrounding skin is the correct method. This technique helps prevent the spread of bacteria from the surrounding skin into the incision site, reducing the risk of infection. Always use a sterile solution and clean gauze for this process.

Choice D Reason:

Using sterile gloves when removing the old dressing is important to maintain a sterile environment and prevent infection. However, this is a general practice and not specific to the wound care instructions provided in the question.

A. Inform the provider of the delay in obtaining the type and cross-match. B. Document the incident in the client’s medical record. C. Prepare an incident report for risk management. D. Obtain the client’s type and cross-match.

Correct Answer is D

Explanation

Choice A Reason:

Informing the provider of the delay in obtaining the type and cross-match is important for keeping the healthcare team informed. However, this action should follow the immediate step of obtaining the type and cross-match to ensure the client has compatible blood available for surgery. Communication with the provider is crucial but secondary to addressing the immediate need.

Choice B Reason:

Documenting the incident in the client’s medical record is necessary for maintaining accurate records and ensuring continuity of care. However, this action should be performed after the immediate need for obtaining the type and cross-match is addressed. Accurate documentation is essential but not the first priority in this situation.

Choice C Reason:

Preparing an incident report for risk management is important for identifying and addressing potential system issues that led to the oversight. However, this action is not the immediate priority. The primary focus should be on obtaining the type and cross-match to ensure the client’s safety during surgery. Incident reporting can be done after the immediate needs are met.

Choice D Reason:

Obtaining the client’s type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery. This step directly addresses the immediate clinical need and prioritizes the client’s safety and readiness for surgery.

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A nurse is preparing to obtain a blood sample from an adult client for a capillary blood glucose test. Which of the following sites should the nurse select?

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