A nurse is preparing to perform a capillary blood glucose test for a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?
Cleanse the client's finger with an antiseptic swab.
Hold the client's finger in a dependent position.
Wipe away the first drop of blood.
Place the lancet on the side of the selected finger.
The Correct Answer is A
A) Cleanse the client's finger with an antiseptic swab: The first step in performing a capillary blood glucose test is to cleanse the client’s finger with an antiseptic swab. This reduces the risk of infection and ensures that any contaminants on the skin do not affect the accuracy of the blood glucose reading.
B) Hold the client's finger in a dependent position: Holding the finger in a dependent position can help increase blood flow, but this step is taken after cleansing the finger. The priority is to first clean the area to minimize the risk of infection.
C) Wipe away the first drop of blood: Wiping away the first drop of blood is done to avoid contamination from interstitial fluid and to ensure a more accurate reading. However, this action occurs after the blood sample is obtained, not before the test begins.
D) Place the lancet on the side of the selected finger: While placing the lancet on the side of the finger is important for minimizing discomfort and obtaining an adequate blood sample, it follows the initial steps of cleaning the finger and preparing for the blood draw.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) A potassium supplement: Administering a potassium supplement would be inappropriate for a client with a potassium level of 6.4 mEq/L. This level is above the normal range (3.5-5.0 mEq/L) and indicates hyperkalemia, which can have serious effects on cardiac function. Increasing potassium intake could exacerbate the condition.
B) A fiber supplement: While fiber supplements can be beneficial for overall digestive health, they do not directly address or correct an electrolyte imbalance like hyperkalemia. They are not relevant in managing elevated potassium levels.
C) An anticonvulsant: Anticonvulsants are used to manage seizure activity and are not indicated for treating hyperkalemia. They do not have any role in the regulation or management of potassium levels in the body.
D) A diuretic: Diuretics, particularly loop diuretics, are often used to help manage hyperkalemia by promoting the excretion of potassium through urine. This helps lower the elevated potassium levels in the blood and reduce the risk of complications such as cardiac arrhythmias. Therefore, administering a diuretic is an appropriate intervention for a client with a potassium level of 6.4 mEq/L.
Correct Answer is B
Explanation
A) "Switch from breastfeeding to formula feeding when your baby is 2 months old": Breastfeeding is associated with a reduced risk of otitis media, as breast milk contains antibodies and other factors that help protect against infections. Switching to formula feeding may not reduce the incidence of otitis media and can potentially increase the risk.
B) "Avoid exposing your baby to secondhand smoke": Exposure to secondhand smoke is a significant risk factor for otitis media. Smoke irritates the respiratory tract and can lead to inflammation and fluid accumulation in the middle ear, increasing the likelihood of ear infections. Avoiding secondhand smoke can help reduce the incidence of otitis media.
C) "Ensure your baby receives the Hepatitis B vaccine": While the Hepatitis B vaccine is important for preventing Hepatitis B infection, it does not have a direct impact on the incidence of otitis media. The vaccine’s primary role is in preventing liver disease rather than ear infections.
D) "Place your baby in a supine position during feeding": Placing a baby in a supine position (lying on their back) during feeding does not reduce the risk of otitis media. In fact, feeding a baby while lying flat can increase the risk of ear infections as it may cause milk to flow into the middle ear. It is generally recommended to hold the baby in an upright or semi-upright position during feeding.
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