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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Place the child in a tub bath of tepid water: While tepid water can help in some situations of hyperthermia, it is not suitable for hypothermia. A more controlled and gradual rewarming method is necessary to prevent further complications such as rewarming shock.

B) Cover the child's head with a hat: Covering the child's head with a hat is an important step in rewarming because a significant amount of body heat is lost through the head. This helps in retaining body heat and stabilizing the child’s temperature.

C) Administer acetaminophen every 4 hr: Acetaminophen is typically used for reducing fever and managing pain. It is not indicated for treating hypothermia, as it does not aid in rewarming the body or addressing the underlying hypothermic condition.

D) Obtain a specimen for blood cultures: While obtaining blood cultures might be necessary if there is a suspicion of infection, it is not a primary intervention for treating hypothermia. Immediate focus should be on rewarming and stabilizing the child.

A. Administer risperidone 25 mg IM. B. Teach the client how to perform guided imagery. C. Stay with the client until the panic attack subsides. D. Encourage the client to take quick, shallow breaths.

Correct Answer is C

Explanation

A) Administering risperidone 25 mg IM is not typically appropriate for treating a panic attack. Risperidone is an antipsychotic medication used for treating conditions like schizophrenia and bipolar disorder, not for the immediate management of panic attacks. Immediate pharmacological intervention is not generally the first line of treatment in acute panic attacks unless the client has a specific medication prescribed for such episodes.

B) Teaching the client how to perform guided imagery can be beneficial for long-term anxiety management but is not the most effective intervention during an acute panic attack. During a panic attack, the client's ability to focus and learn new techniques may be impaired, making it less effective in the immediate situation.

C) Staying with the client until the panic attack subsides is the most appropriate action. Presence and reassurance from the nurse can help the client feel safer and more grounded. This approach provides emotional support and can help reduce the severity and duration of the panic attack by addressing the client's immediate need for security and stability.

D) Encouraging the client to take quick, shallow breaths can exacerbate hyperventilation and increase anxiety during a panic attack. Instead, slow, deep breathing techniques are recommended to help calm the client's physiological response and reduce the intensity of the panic attack.

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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?

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Naxlex Comprehensive Predictor Exams

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