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The nurse is preparing to perform a blood glucose monitoring test on a patient. Place the steps for performing the procedure in the correct sequence.

A.

Press button on meter to confirm match codes.

B.

Bringing meter to test strip, allow blood drop to wick onto test strip.

C.

Instruct patient to perform hand hygiene with soap and water.

D.

Clean patient finger with antiseptic swab.

E.

Interpret results and document.

F.

Check code on test strip vial.

G.

Holding lancet to finger, press release button on machine.

H.

Perform hand hygiene and put on clean gloves.

Answer and Explanation

The Correct Answer is C,F,A,H,D,G,B,E

Point-of-care blood glucose monitoring must combine infection control, correct technique, and device accuracy. Steps done in the right order reduce false readings and prevent transmission of infection.

Rationale for correct answer:

  1. (3) Instruct patient to perform hand hygiene with soap and water.
    Prevents contamination from sugar or other residues on the fingers, which could give falsely high readings.
  2. (6) Check code on test strip vial.
    Ensures the test strips are calibrated correctly for the glucometer.
  3. (1) Press button on meter to confirm match codes.
    Confirms that the meter’s internal code matches the strip code for accuracy.
  4. (8) Perform hand hygiene and put on clean gloves.
    Protects both nurse and patient from bloodborne pathogens and infection transmission.
  5. (4) Clean patient finger with antiseptic swab.
    Disinfects the puncture site. Important: allow to dry to avoid dilution of blood with alcohol.
  6. (7) Holding lancet to finger, press release button on machine.
    Obtains capillary blood sample safely and effectively.
  7. (2) Bringing meter to test strip, allow blood drop to wick onto test strip.
    Ensures an adequate sample is absorbed by the strip for analysis.
  8. (5) Interpret results and document.
    Completes the procedure and ensures accurate communication of results for clinical decision-making.

Take home points:

  • Correct sequence matters: code verification comes before gloves and antiseptic.
  • Always finish with interpretation and documentation- this closes the loop on safe patient care.


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Related Questions

Correct Answer is B

Explanation

Continuous enteral feedings increase aspiration risk and require careful positioning and securement. When delegating or observing AP care, the nurse must intervene immediately for actions that increase aspiration or dislodge the tube.

Rationale for correct answer:

2. Placing patient supine while giving a bath: Supine position during ongoing feedings greatly increases risk of reflux and aspiration. The head of bed should be elevated (usually 30–45°) during continuous enteral feeding.

Rationale for incorrect answers:

1. Fastening tube to the gown with new tape: Appropriate and good practice to prevent tube dislodgement as long as the tube is secured without tension and the tape is applied correctly.

3. Monitoring the patient’s weight as ordered: Appropriate nursing activity; weight monitoring is part of routine assessment for nutritional status and tube-feeding effectiveness.

4. Ambulating patient with enteral feedings still infusing: Often acceptable if the feeding is on a pump, tubing is secured, and patient stability/transfer protocols are followed.

Take home points:

  • Never allow a patient to be supine during continuous enteral feeding - always keep HOB elevated (30-45°) to reduce aspiration risk.
  • Secure the tube properly and monitor safety during ambulation; intervene immediately for positioning or securement practices that increase aspiration/dislodgement risk.

Correct Answer is A

Explanation

Changing parenteral nutrition (PN) tubing involves central venous access in many patients. Any open central line connection can allow air to be entrained into the venous system; increasing intrathoracic/central venous pressure during the change and positioning the patient appropriately reduces that risk.

Rationale for correct answer:

1. Have the patient turn on the left side and perform a Valsalva maneuver: The Valsalva increases intrathoracic and central venous pressure so air is less likely to be sucked into the central venous catheter during disconnection. Placing the patient on the left side helps trap any entrained air in the right atrium/ventricle and away from the pulmonary outflow.

Rationale for incorrect answers:

2. Have the patient cough vigorously when tubing is disconnected: Coughing can transiently raise intrathoracic pressure but is uncontrolled and may dislodge lines or cause complications.

3. Have the patient take a deep breath and hold it: Holding a deep breath raises intrathoracic pressure somewhat, but a true Valsalva (forced expiration against a closed glottis or “bear down”) is more effective.

4. Place patient in supine position with head of bed elevated 90 degrees: Head-up positioning lowers central venous pressure and increases the risk of air being entrained.

Take home points:

When manipulating central lines or changing PN tubing:

  • clamp the catheter when possible
  • prime tubing carefully to remove air
  • have the patient perform a Valsalva or exhale-and-hold during disconnection to raise central venous pressure

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