A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?

Select the central tip of a finger.

Wear sterile gloves.

Keep the finger in a dependent position.

Milk or massage the finger site.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Select the central tip of a finger is incorrect. The nurse should select a puncture site on the side of the finger, slightly off-center from the central tip, as it tends to be less painful. The side of the finger has an adequate blood supply and can provide an accurate blood sample without causing excessive discomfort.

Choice B Reason:

Wearing sterile gloves is incorrect. Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. However, clean hands and proper hand hygiene are essential. The nurse should perform hand hygiene before the procedure.

Choice C Reason:

Keeping the finger in a dependent position is correct. Keeping the finger in a dependent position (hanging down) can promote blood flow and make it easier to obtain a blood sample. This is a recommended technique to facilitate the puncture and collection of blood.

Choice D Reason:

Milking may hemolyze specimen and introduce excess tissue fluid.

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Correct Answer is D

Explanation

Choice A Reason:

Chloasma is incorrect. Chloasma, also known as the "mask of pregnancy," refers to the brownish or tan patches of pigmentation that can appear on the face during pregnancy. It is not related to the purplish discoloration of the cervix, vagina, and vulva described in the scenario.

Choice B Reason:

Hegar's sign is incorrect. Hegar's sign is a softening and compressibility of the lower uterine segment (the area between the cervix and the body of the uterus) that can be felt during a pelvic examination. It is not related to discoloration of the genital area.

Choice C Reason:

Ballottement is incorrect. Ballottement is a technique used during a pelvic examination to assess the fetus's position and is characterized by the examiner feeling a rebound movement of the fetus when it is pushed and then released. It does not involve discoloration of the genital area.

Choice D Reason:

Chadwick's sign is a bluish-purple or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. This discoloration is due to increased blood flow to the pelvic area and is considered a normal physiological change during pregnancy. It is one of the early signs of pregnancy and can be observed as early as the sixth week of gestation. It is named after the American obstetrician James Read Chadwick, who first described it.

A. Pain sensation B. Urinary output C. Heart rhythm D. Muscle strength

Correct Answer is C

Explanation

Choice A Reason:

Pain sensation is incorrect. While assessing pain is important, it's generally secondary to addressing the life-threatening cardiac issues in hypothermia. Pain assessment can be done once the client's core temperature is stabilized.

Choice B Reason:

Urinary output is incorrect. Monitoring urinary output is essential for assessing kidney function and fluid balance, but it is not as immediately critical as assessing and addressing cardiac concerns.

In a client with hypothermia, the priority for the nurse to monitor is:

Choice C Reason:

Heart rhythm is correct. Hypothermia can affect the electrical conductivity of the heart, potentially leading to life-threatening arrhythmias. Monitoring the client's heart rhythm is essential to detect any abnormalities and intervene promptly if necessary. While all the listed parameters are important, the cardiac status takes precedence due to the immediate threat it poses to the client's life.

Choice D Reason:

- Muscle strength is incorrect. Monitoring muscle strength is important to assess the client's overall neurological status, but it's not the top priority when there is a risk of life-threatening arrhythmias due to hypothermia.

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A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?

Nursing Test Bank

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