A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?
Wrapping the finger in a warm cloth
Rubbing the fingertip with an alcohol pad
Puncturing the side of the fingertip
Elevating the finger above heart level
The Correct Answer is D
A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.
C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.
D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. The two-point gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg.
B. The four-point gait also requires weight-bearing on both legs and provides maximum stability, but it is not appropriate for a client who can bear weight on only one leg.
C. The swing-through gait is generally used by clients with paralysis of the legs or for those who need to use both legs minimally while moving with crutches. It is not the most suitable option for a client with weight-bearing restrictions on one leg.
D. The three-point gait is the correct technique for a client who can bear weight on only one leg. In this gait, both crutches and the affected leg are moved forward together, followed by the weight-bearing leg. This method allows the client to ambulate safely while maintaining the non-weight-bearing leg off the ground.
Correct Answer is B
Explanation
A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping
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