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.)

Pierce the puncture site quickly.

Allow the site to dry.

Cleanse the site with an antiseptic swab.

Apply blood to the test strip.

Squeeze the site gently to obtain a blood droplet.

Answer and Explanation

Correct Answer : A,B,C,E

A. Pierce the puncture site quickly: The puncture is performed after proper site preparation and drying to minimize pain and reduce the risk of contamination. A quick puncture ensures adequate blood flow and less tissue trauma.

B. Allow the site to dry: After cleansing the site with an antiseptic swab, allowing it to air dry prevents alcohol or antiseptic residue from contaminating the blood sample. Residual moisture can interfere with test accuracy and cause stinging.

C. Cleanse the site with an antiseptic swab: Proper cleansing reduces the risk of infection at the puncture site. The site should be wiped using a circular motion and then allowed to dry completely before puncturing.

D. Apply blood to the test strip: Once a sufficient blood droplet is obtained, it is applied directly to the glucose test strip for accurate measurement. Proper application ensures the meter reads the correct glucose concentration.

E. Squeeze the site gently to obtain a blood droplet: Gentle pressure helps produce an adequate blood droplet without causing tissue trauma or hemolysis. Excessive squeezing can dilute the sample with interstitial fluid, affecting accuracy.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Probiotics: Probiotics support gut health and do not have significant anticoagulant effects. Their use does not increase bleeding risk or interact directly with enoxaparin, so reporting is not usually necessary.

B. Ginkgo biloba: Ginkgo biloba can increase the risk of bleeding by inhibiting platelet aggregation, which may potentiate the anticoagulant effect of enoxaparin. This combination can lead to serious bleeding complications, so the provider should be informed.

C. Echinacea: Echinacea primarily supports immune function and does not significantly affect coagulation or interact with enoxaparin. Reporting its use is not critical for anticoagulation safety.

D. Flaxseed powder: Flaxseed provides fiber and omega-3 fatty acids but has minimal anticoagulant effect. While it may slightly influence bleeding in large amounts, it is not as concerning as ginkgo and does not typically require immediate provider notification.

A. A B. C C. C

Correct Answer is C

Explanation

A. The top image shows a client's neck with a visible swelling in the area of the thyroid gland, which is consistent with goiter, another common finding in Graves' disease, but is not exophthalmos.
B. The middle image shows a hand, which is not relevant to the ocular manifestations of this condition.
C. The bottom image shows the client's eyes with a noticeable bulging appearance and retracted eyelids, making the whites of the eyes visible above and below the iris. This is the characteristic clinical appearance of exophthalmos

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has Graves' disease. Which of the following images should the nurse identify as an indication that the client is experiencing exophthalmos?

Correct Answer is C

Explanation

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