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 D

Explanation

Weakened cough effort can lead to ineffective airway clearance and increase the risk of aspiration pneumonia, a common complication in ALS due to bulbar muscle involvement. Aspiration pneumonia is a serious and potentially life-threatening condition that requires immediate intervention
A This symptom can be distressing for the client and may impact their quality of life. While it should be addressed and managed, it does not pose an immediate threat to the client's physical health.
B Asymmetrical weakness is a hallmark feature of ALS, where muscle weakness typically begins in one region of the body and gradually spreads to other areas. While it signifies disease progression and may impact the client's mobility and function, it does not necessarily require immediate intervention.
C Anxiety is a common emotional response in clients with ALS, especially as the disease progresses and the client faces physical decline and uncertainty about the future. While it is important to address the client's emotional well-being and provide support, increasing anxiety does not usually warrant immediate intervention.

A. Decrease the flow rate. B. Irrigate the catheter manually. C. Discontinue infusing solution. D. Monitor catheter drainage.

Correct Answer is B

Explanation

A. The irrigation solution is typically maintained at a continuous rate to prevent clot formation and maintain catheter patency, which is important for promoting urinary drainage and preventing obstruction.
B. This involves injecting more saline into the bladder through the catheter to help break up and flush out the clots. This should be done carefully and gently to avoid causing any damage or discomfort.

C. Discontinuing the infusion solution may not be necessary or appropriate, as the continuous bladder irrigation (CBI) solution is typically maintained at a continuous rate to prevent clot formation and maintain catheter patency after a TURP procedure.

D.While it's important to monitor the drainage, simply observing won't address the issue of the clots.

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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

While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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