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 A random plasma glucose level of 200 mg/dL (11.1 mmol/L) is indicative of hyperglycemia and suggests possible diabetes mellitus. This finding is significant and should be reported promptly to the healthcare provider for further evaluation and management.
D Hemoglobin A1C (HbA1C) is a measure of average blood glucose levels over the past 2-3 months. A level of 7% indicates poorly controlled diabetes, as the target for most individuals with diabetes is less than 7%. This finding suggests inadequate glycemic control and requires attention from the healthcare provider for adjustment of treatment regimen.
A While total cholesterol levels are important for assessing cardiovascular risk, a value of 180 mg/dL is within the desirable range (less than 200 mg/dL) and is not directly related to the symptoms reported by the client.
B Hematocrit levels within the reference range do not directly relate to the symptoms reported by the client and are not indicative of the underlying cause of frequent urination, hunger, and great thirst.

E While serum potassium levels are important for assessing electrolyte balance, a value of 4.2 mEq/L is within the normal reference range (3.5 to 5 mEq/L) and is not directly related to the symptoms reported by the client.

A. The client’s blood pressure reading will be less than 160/90 mm Hg. B. The client's daily blood pressure will be less than 140/80 mm Hg this month. C. The client's family will repeat signs and symptoms about the disease. D. The nurse will encourage the client to walk thirty minutes every day.

Correct Answer is B

Explanation

A. While this is a good goal, it's not the most stringent and may not adequately control blood pressure to prevent further complications.
B. This is a more specific and achievable goal for a client with newly diagnosed hypertension. It aligns with recommended blood pressure targets for optimal cardiovascular health.
C. While education and reinforcement of disease signs and symptoms are important aspects of care for clients with cardiovascular disease, this outcome does not directly address the client's current concern of blurred vision or contribute to the management of cardiovascular disease- related complications such as hypertension.
D. Regular physical activity, such as walking, is an essential component of cardiovascular disease management and can help improve blood pressure control and overall cardiovascular health.
However, while exercise promotion is an important aspect of care, it does not specifically address the client's immediate concern of blurred vision or the need for blood pressure management.

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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

Correct Answer is C

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is B

Explanation

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