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:

Irrigation of a wound with antibiotic solution is incorrect. Typically, irrigation of a wound with antibiotic solution doesn't require informed consent unless there are specific factors or risks involved that require it. This is usually considered a routine wound care procedure.

Choice B Reason:

Administration of an iron injection using Z-track technique is incorrect. Informed consent may not be required for this procedure if it's a routine and commonly performed nursing intervention. However, if there are specific concerns or potential risks (e.g., allergy to the medication), informed consent might be necessary.

Choice C Reason:

Insertion of a nasogastric tube is correct. Insertion of a nasogastric tube generally requires informed consent, especially if it's a non-emergent procedure. Informed consent is essential because there can be risks associated with the insertion, and the client should be informed and agree to it.

Choice D Reason:

Placement of a central venous catheter is correct. Placement of a central venous catheter definitely requires informed consent. It's a more invasive procedure that involves entering a major blood vessel, and there are specific risks and potential complications associated with it.

A. "Fidelity involves ensuring that we do no harm to the client." B. "Fidelity involves keeping promises made to clients." C. "Fidelity involves making sure clients are able to make their own health care decisions." D. "Fidelity involves treating every client with the same level of respect."

Correct Answer is B

Explanation

Choice A Reason:

"Fidelity involves ensuring that we do no harm to the client.” This statement is more closely related to the ethical principle of nonmaleficence, which means "do no harm." Nonmaleficence focuses on avoiding harm and preventing any potential harm to the client.

Choice B Reason:

"Fidelity involves keeping promises made to clients." Fidelity is an ethical principle related to faithfulness, honesty, and keeping promises made to clients. It involves maintaining trust and being loyal to the client's best interests. This principle emphasizes the importance of nurses and healthcare providers honoring their commitments and obligations to clients, which helps build and maintain trust in the nurse-client relationship.

Choice C Reason:

"Fidelity involves making sure clients are able to make their own health care decisions. “This statement is more aligned with the ethical principle of autonomy, which emphasizes a person's right to make their own decisions about their healthcare. Autonomy relates to respecting a client's right to self-determination and informed consent.

Choice D Reason:

"Fidelity involves treating every client with the same level of respect." This statement is associated with the ethical principle of justice, which involves treating individuals fairly and equally and ensuring that they receive equitable care. It is about fairness and equality rather than the specific concept of keeping promises.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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