The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Select another finger.

Assess radial pulse volume.

Collect the blood sample.

Apply pressure to the site.

Answer and Explanation

The Correct Answer is D

D. Applying pressure to the site helps to reduce engorgement and promote normal blood flow. This action can help alleviate the localized congestion and ensure a more accurate fingerstick glucose measurement. Once the pressure is applied and the congestion subsides, the nurse can proceed with collecting the blood sample.
A. While selecting another finger may be considered if the initial fingerstick attempt was unsuccessful or if the fingertip is excessively traumatized, it may not be necessary if the observation of redness and engorgement can be addressed with appropriate pressure application to the site.
B. Assessing radial pulse volume is not directly relevant to addressing the observed redness and engorgement of the fingertip after milking. This action is more appropriate for evaluating peripheral circulation and arterial perfusion in other clinical contexts
C. Collecting the blood sample without addressing the observed redness and engorgement of the fingertip may result in a suboptimal sample quality and could cause discomfort or further tissue trauma to the client.

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Correct Answer is C

Explanation

C. In glaucoma management, the use of topical eye drops to reduce intraocular pressure is a cornerstone of treatment. These medications work to decrease fluid production in the eye or increase fluid drainage, thereby lowering IOP and reducing the risk of optic nerve damage and vision loss. Adherence to the prescribed eye drop regimen is crucial for controlling IOP and preventing further vision deterioration.
A. While wearing prescription glasses may be important for correcting vision problems, such as nearsightedness or farsightedness, they do not directly address the underlying issue of increased intraocular pressure associated with glaucoma.
B. While maintaining a healthy diet rich in nutrients, including carotene, is important for overall eye health, there is no evidence to suggest that it directly affects the progression of glaucoma or intraocular pressure.
D. Regular monitoring of intraocular pressure is an essential part of managing glaucoma. Frequent eye pressure measurements help assess the effectiveness of treatment and detect any changes in intraocular pressure that may indicate progression of the disease.

A. Administer antiemetic B. Monitor for adverse reaction to antibiotics C. Increase IV fluids to 150 mL/hr D. Initiate airborne isolation E. Repeat CD4+ T-cell count STAT

Correct Answer is ["A","B","C"]

Explanation

A. The client is noted to have emesis which contributes to total fluid loss predisposing the client to acute kidney injury. Antiemetics are important to reduce emesis.
B. Clients with PCP are typically treated with antibiotics, such as trimethoprim-sulfamethoxazole (TMP-SMX), as first-line therapy. Monitoring for adverse reactions to antibiotics, such as hypersensitivity reactions or renal toxicity, is essential for safe medication administration.
Increasing fluid intake prevents and manages acute kidney injury in the client.
C. Increasing intravenous hydration ensures the lost fluid is replaced to prevent acute renal injury that may occur due to hypoperfusion.
D. Pneumocystis pneumonia is caused by the fungus Pneumocystis jirovecii (formerly known as Pneumocystis carinii), and its transmission occurs through the inhalation of airborne fungal spores. However, it is not typically spread from person to person like airborne viral or bacterial infections.
E. Repeating CD4 count is not necessary as it is unlikely to alter the management of the client at this point. This should be after 2-3 weeks.

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The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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