A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

Elevate the client's hand above the level of the heart.

Squeeze the client's finger until a blood drop forms.

Prick the side of the client's finger.

Apply clean gloves.

Cleanse the client's finger with an iodine swab.

Answer and Explanation

Correct Answer : C,D

A. Elevate the client's hand above the level of the heart.: The hand should be kept dependent (below heart level) to increase blood flow to the fingertips.

B. Squeeze the client's finger until a blood drop forms.: Excessive squeezing (milking) can cause hemolysis or dilute the specimen with interstitial fluid.

C. Prick the side of the client's finger.: The sides of the finger have fewer nerve endings and better vascularity than the center of the fingertip.

D. Apply clean gloves.: Standard precautions must be followed when handling blood.

E. Cleanse the client's finger with an iodine swab.: Iodine can interfere with results (especially glucose). Alcohol is typically used and must be allowed to dry completely.

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Correct Answer is A

Explanation

A. Uses firm, circular motions to wash his hands: Friction is the most important component of handwashing because it physically loosens and removes microorganisms from the skin.

B. Washes his hands under hot running water: Hot water can cause dermatitis and increase skin irritation. Warm water is recommended to preserve skin integrity.

C. Scrubs hands with antibacterial soap for 10 seconds: The CDC and standard nursing practice recommend scrubbing for at least 20 seconds to effectively remove pathogens.

D. Dries his hands from the forearms to the fingers: Hands should be dried from the cleanest area (fingers) to the least clean area (forearms) to prevent re-contaminating the hands.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Correct answer: The client is at risk for Aspiration as evidenced by the client's Dysphagia.

i. Aspiration: The client is exhibiting classic signs of dysphagia (difficulty swallowing), specifically "feeling food stuck in their mouth" and a "hoarse vocal quality." When a client cannot swallow effectively, food or liquid can enter the airway instead of the esophagus, leading to aspiration pneumonia.

ii. Dysphagia: This is the clinical term for the symptoms described in the Nurses' Notes (hoarseness and food pocketing). While the client does have a slightly elevated blood pressure and heart rate, these are secondary to the primary safety risk of an impaired airway/swallow reflex.

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A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) who is performing hand hygiene. The nurse should recognize that the AP is using proper technique when he does which of the following?

Correct Answer is A

Explanation

A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day. Complete the following sentence by using the list of options. The client is at risk for _____ as evidenced by the client's _____

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

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