A nurse is preparing to perform a blood glucose test.
After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?

(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Squeeze the site gently to obtain a blood droplet.

Allow the site to dry.

Apply blood to the test strip.

Cleanse the site with an antiseptic swab.

Pierce the puncture site quickly.

Answer and Explanation

The Correct Answer is D,B,E,A,C

Choice D rationale

Cleansing the site with an antiseptic swab reduces the risk of infection by removing surface bacteria and contaminants. It is essential to prepare the site adequately for a clean puncture.

Choice B rationale

Allowing the site to dry prevents the antiseptic from diluting the blood sample and ensures accurate readings. Moisture at the puncture site can interfere with the effectiveness of the glucose meter.

Choice E rationale

Piercing the puncture site quickly minimizes discomfort for the client and ensures a clean puncture. A swift puncture reduces the risk of the site becoming overly irritated or bruised.

Choice A rationale

Squeezing the site gently helps to obtain an adequate blood sample without causing excessive damage to the surrounding tissue. It ensures a sufficient droplet size for testing without causing additional trauma.

Choice C rationale

Applying blood to the test strip allows the glucose meter to measure the blood glucose level accurately. It is the final step in obtaining a capillary blood sample for testing. .

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice C rationale

A delayed response to verbal commands is a sign of increased intracranial pressure, indicating possible brain function impairment due to the pressure.

Choice A rationale

Ecchymosis around the eyes, known as "raccoon eyes," can indicate a basal skull fracture but does not directly indicate increased intracranial pressure.

Choice B rationale

Ringing in the ears, or tinnitus, is not a specific sign of increased intracranial pressure. It is usually related to auditory or vestibular issues.

Choice D rationale

Inability to remember details of the motor-vehicle crash can indicate a concussion or other brain injury but is not solely indicative of increased intracranial pressure. .

A. "I will apply heat to my affected ankle to decrease swelling.”. B. "I will wrap my affected ankle with an elastic bandage.”. C. "I can dangle my affected ankle from the edge of the bed.”. D. "I can bear full weight on my affected ankle.”.

Correct Answer is B

Explanation

Choice A rationale

Applying heat to a sprained ankle can increase swelling and should be avoided. Ice should be used instead to reduce swelling.

Choice B rationale

Wrapping the affected ankle with an elastic bandage helps to provide support, reduce swelling, and immobilize the joint.

Choice C rationale

Dangling the affected ankle can cause further injury and increase swelling. The ankle should be elevated to reduce swelling.

Choice D rationale

Bearing full weight on a sprained ankle can exacerbate the injury. The client should avoid putting weight on the ankle until it has healed sufficiently.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash.For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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