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?
Collect the blood sample.
Select another finger.
Apply pressure to the site.
Assess radial pulse volume.
The Correct Answer is B
A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.
B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.
C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.
D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing the pin sites for signs of infection is essential in clients with skeletal traction to detect any early signs of infection, such as redness, swelling, warmth, or purulent drainage. Prompt identification and management of pin site infections can prevent complications.
B. Administering pain medication at designated intervals around the clock helps to ensure adequate pain control and comfort for the client. However, this intervention alone does not specifically address the care needs related to skeletal traction.
C. Assessing the pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this assessment is not directly related to the care of skeletal traction itself.
D. Removing traction every shift is not indicated unless there is a specific reason to do so as ordered by the healthcare provider. Continuous traction is often necessary for proper alignment and stabilization of the fracture. Additionally, providing skin care is important to prevent skin breakdown around the traction device, but removing traction every shift is not part of routine care.
Correct Answer is D
Explanation
A. Asking about the effectiveness of antifungal creams is not relevant to herpes zoster, which is caused by the varicella-zoster virus.
B. Inquiring about family members sharing combs and brushes is not directly related to herpes zoster, as it is not transmitted through sharing personal items.
C. Asking about dry patches on the feet and hands may provide information about other dermatological conditions but does not specifically address herpes zoster.
D. Asking whether everyone at home has already had varicella is important because herpes zoster, commonly known as shingles, is caused by reactivation of the
varicella-zoster virus, which also causes chickenpox (varicella). Individuals who have not had chickenpox or been vaccinated against it may be at risk of developing chickenpox if exposed to herpes zoster lesions.
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