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.)

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

Prick the side of the client's finger.

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

Cleanse the client's finger with an iodine swab.

Apply clean gloves.

Answer and Explanation

Correct Answer : B,E

A. Squeezing the client’s finger should be avoided as it can cause hemolysis and affect the accuracy of the blood sample.

B. Pricking the side of the client’s finger is recommended as it tends to be less painful and reduces tissue damage.

C. Elevating the hand above the heart level could reduce blood flow, making it more difficult to obtain a sample.

D. An alcohol swab, not iodine, is typically used to cleanse the site for a capillary blood draw, as iodine can interfere with certain lab results.

E. Applying clean gloves is a standard precaution to prevent contamination and protect both the nurse and the client.

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Correct Answer is A

Explanation

A. The sterile solution is poured with the bottle held over the field: Pouring a sterile solution directly over the sterile field can cause contamination due to the possibility of the bottle touching the sterile field or splashing. The correct procedure involves holding the bottle above the sterile field, ensuring it does not touch the field, and pouring the solution at a distance to prevent contamination.

B. Unnecessary sterile items are placed on the field: While unnecessary items on the sterile field are undesirable, it does not automatically contaminate the field. The field remains sterile if these items are sterile and are handled appropriately, even if not needed for the procedure. However, this action should still be avoided.

C. A pair of sterile forceps is allowed to rest in a container of sterile water on the field: As long as both the forceps and water are sterile, this does not contaminate the sterile field. Forceps can rest in sterile water, as long as care is taken not to touch any non-sterile surfaces.

D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge: The sterile scissors handle resting just outside the sterile field does not contaminate it, as long as it does not touch any non-sterile surfaces.

A. "I'll use focused breathing to control my pain." B. "1’l1 learn to notice the sensation of muscle tension." C. "I think about my grandfather's farm to reduce pain." D. "I listen to my favorite music to take my mind off the pain."

Correct Answer is C

Explanation

A. Focused breathing is part of relaxation techniques but is not the same as guided imagery.

B. Noticing muscle tension is part of progressive muscle relaxation, not guided imagery.

C. Guided imagery involves visualizing a pleasant or calming scene (such as a farm) to distract from pain and promote relaxation.

D. Listening to music can be helpful for relaxation but is a separate strategy from guided imagery.

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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

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Correct Answer is C

Explanation

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