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.)

Cleanse the site with an antiseptic swab.

Allow the site to dry.

Pierce the puncture site quickly.

Squeeze the site gently to obtain a blood droplet.

Apply blood to the test strip.

Answer and Explanation

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

A. Cleanse the site with an antiseptic swab: Begin by cleaning the puncture site to reduce the risk of infection. B. Allow the site to dry: Let the antiseptic dry completely to prevent contamination or dilution of the blood sample. C. Pierce the puncture site quickly: Use a lancet to pierce the skin in one swift motion to minimize discomfort. D. Squeeze the site gently to obtain a blood droplet: Gently apply pressure to the site to encourage a droplet of blood to form. E. Apply blood to the test strip: Once the blood droplet forms, apply it to the test strip for analysis.

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Correct Answer is C

Explanation

Choice A Reason:

Instructing the client to tilt their head back to facilitate swallowing is not appropriate. Tilting the head back can increase the risk of aspiration (food or liquid entering the airway) for individuals with dysphagia. Instead, the client should maintain an upright position while eating.

Choice B Reason:

Encouraging the client to use a straw is inappropriate. Using a straw might increase the risk of aspiration because it can bypass the control mechanisms involved in safe swallowing, especially for someone with swallowing difficulties.

Choice C Reason:

Providing oral care before meals is correct. Providing oral care before meals helps to ensure that the client's mouth is clean, reducing the risk of infections and improving taste perception, which can enhance the client's willingness and ability to eat.

Choice D Reason:

Schedule physical therapy directly before meals is incorrect. Scheduling physical therapy directly before meals might tire the client and impact their ability to eat. Fatigue can negatively affect swallowing ability, so it's generally better to allow some rest or recovery time before meals.

A. Administer enemas 2 days before the procedure. B. Do not eat or drink anything except water for 12 hr. before the procedure. C. Restrict the diet to clear liquids for 1 to 3 days before the procedure. D. Expect the provider to schedule another procedure to remove any polyps.

Correct Answer is B

Explanation

a.While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.

b.This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.

c.A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.

d.Removing polyps during a colonoscopy is a common procedure and does not necessarily require a separate procedure.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?

A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?

A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?

A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?

A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?

A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?

A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?