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)

Apply clean gloves.

Prick the side of the client's finger.

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

Cleanse the client's finger with an iodine swab.

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

Answer and Explanation

Correct Answer : A,B,E

A. Apply clean gloves: Correct. Gloves should be worn to maintain hygiene and prevent contamination during the blood collection process.

B. Prick the side of the client's finger: Correct. The side of the finger is preferred for capillary blood collection to avoid pain and to ensure a sufficient blood flow.

C. Squeeze the client's finger until a blood drop forms: Incorrect. Squeezing the finger can cause hemolysis and affect the accuracy of the results. Gentle pressure or massaging the area prior to pricking is preferred.

D. Cleanse the client's finger with an iodine swab: Incorrect. Iodine is not used for capillary blood collection; instead, an alcohol swab is used to cleanse the site to prevent contamination and ensure accurate results.

E. Elevate the client's hand above the level of the heart: Correct. Elevating the hand can help with blood flow to the site and improve the ease of obtaining a sample.

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Correct Answer is B

Explanation

A. Contact facility security to remove the nurse from the unit: This action may be excessive unless there is immediate and clear evidence of misuse or theft of information.

B. Complete an incident report about the breach of confidentiality: Completing an incident report is appropriate to document and address the breach of confidentiality according to facility policies.

C. Remind the nurse that only staff caring for the client may access the client's record: While important, reminding the nurse does not address the breach formally or ensure proper documentation and follow-up.

D. Tell the nurse that permission from the risk manager is required to view the client's record: This step does not address the immediate issue of unauthorized access and lacks documentation of the incident.

A. Assess the pain level of a client who has received acetaminophen. B. Measure the intake and output of a client who has received furosemide. C. Check a client's peripheral IV site for redness or swelling. D. Reinforce teaching with a client about crutch-gait walking.

Correct Answer is B

Explanation

A. Assess the pain level of a client who has received acetaminophen: Assessing pain levels is within the scope of nursing responsibilities and requires clinical judgment and assessment skills.

B. Measure the intake and output of a client who has received furosemide: Measuring intake and output is an appropriate task for an AP, as it is a routine measurement that does not require clinical assessment or judgment.

C. Check a client's peripheral IV site for redness or swelling: This task requires clinical judgment and assessment skills, which are beyond the typical scope of an AP’s duties.

D. Reinforce teaching with a client about crutch-gait walking: Reinforcing teaching requires understanding and reinforcing complex information, which is typically within the nurse’s role, not the AP’s.

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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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