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 A

Explanation

A. Right-sided heart failure can lead to systemic venous congestion, resulting in symptoms such as pitting edema in the lower extremities and jugular venous distention. Increased central venous pressure is also characteristic of right-sided heart failure.
B. Left ventricular dysfunction typically presents with symptoms of pulmonary congestion, such as dyspnea, orthopnea, and crackles on lung auscultation. While left ventricular dysfunction can lead to right-sided heart failure over time, it is not typically associated with pitting edema of the lower extremities or jugular venous distention.
C. Cardiac tamponade is a medical emergency characterized by compression of the heart due to fluid accumulation in the pericardial sac, leading to impaired cardiac filling and hemodynamic compromise. While jugular venous distention may be present in cardiac tamponade due to elevated central venous pressure, pitting edema of the lower extremities is not a typical finding.
D. Internal bleeding may cause hypovolemia and hemodynamic instability, but it typically does not present with the specific findings of pitting edema of the lower extremities and jugular venous distention with increased central venous pressure.

A. Increase Intake of potassium rich foods such as bananas or cantaloupe. B. Restrict protein intake by limiting meats and other high protein foods. C. C Limit oral fluid intake to 500 mL/day. D. D Increase intake of high fiber foods, such as bran cereal.

Correct Answer is B

Explanation

B Restricting protein intake can help reduce the workload on the kidneys and minimize proteinuria (excess protein in the urine), which is common in glomerulonephritis. Limiting high-

protein foods, especially animal proteins, can help slow the progression of kidney damage and preserve kidney function.
A Increasing potassium intake is generally not recommended in glomerulonephritis, especially if the client has hyperkalemia (elevated potassium levels). In kidney disease, potassium levels can become elevated due to decreased excretion by the kidneys.
C Limiting oral fluid intake to 500 mL/day is not a suitable recommendation for most clients with glomerulonephritis. Adequate hydration is important for maintaining kidney function and preventing complications such as dehydration and electrolyte imbalances.
D While increasing fiber intake is generally beneficial for overall health and gastrointestinal function, it is not a specific dietary recommendation for clients with glomerulonephritis.

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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?

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Correct Answer is A

Explanation

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

Correct Answer is B

Explanation

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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?