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.

Apply clean gloves.

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.

Answer and Explanation

Correct Answer : B,C,E

A. Squeezing the client's finger until a blood drop forms can result in hemolysis and inaccurate results; instead, gentle milking or massaging of the finger is recommended.
B. Applying clean gloves is necessary to maintain infection control practices.

C.   Pricking the side of the client's finger is the appropriate technique for obtaining a capillary blood specimen.
D.   Elevating the client's hand above the level of the heart is not necessary and may impede blood flow.

E.   Cleansing the client's finger with an iodine swab helps to disinfect the area prior to obtaining the blood specimen.

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Correct Answer is C

Explanation

A. While obtaining consent from the client is ideal, it may not be appropriate if the client is unable to understand and make an informed decision due to their developmental disability.

B. The provider cannot sign the consent form in place of the legal guardian or the patient, as this would be a conflict of interest.

C. In emergency situations where delaying the procedure could jeopardize the client's life, and the appointed guardian cannot be reached, implied consent is assumed. This means that life-saving treatment can proceed without formal consent.

D. Postponing an emergency procedure that is necessary to save the client's life is not appropriate. In such cases, the surgery should proceed under implied consent.

A. "I will apply a thin layer of talc powder around the stoma before placing the appliance." B. "I will cut an opening in the skin barrier that is 1⁄2 inch larger than the stoma." C. "I will press on the skin barrier for 30 seconds to ensure that it adheres." D. "I will clean around the stoma with a moisturizing soap."

Correct Answer is C

Explanation

A. Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.

B. The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.

C. Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.

D. Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.

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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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