When obtaining a capillary blood sample for glucose measurement, which intervention should the practical nurse (PN) implement?
Determine which finger was used previously
Remove any nail polish from the fingernails.
Apply a tourniquet above the antecubital fossa
Grasp the subcutaneous tissue and pull upward
The Correct Answer is A
A. Repeatedly using the same site can cause pain, scarring (calluses), and tissue damage, which may eventually make it harder to obtain an accurate sample. The nurse must assess previous sites to ensure rotation. The side of the finger (lateral aspect) is the preferred site because it has fewer nerve endings than the central fingertip and is highly vascular.
B. Nail polish does not interfere with a capillary blood glucose reading, as the puncture is made into the skin of the fingertip, not through the nail bed. (Note: Nail polish does need to be removed for pulse oximetry if it interferes with the sensor).
C. Apply a tourniquet above the antecubital fossa: Tourniquets are used for venipuncture, not for capillary fingerstick sampling. Applying one here is unnecessary and inappropriate for capillary blood collection.
D. Grasp the subcutaneous tissue and pull upward: Proper technique involves gently massaging or warming the finger to increase blood flow, but pulling the tissue upward is unnecessary and may cause discomfort or inaccurate results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Offer blankets and thick socks for increased warmth and comfort: Providing warmth promotes relaxation and comfort, which can naturally enhance sleep onset in older adults. Maintaining an optimal sleep environment is an effective nonpharmacologic intervention for insomnia without causing morning drowsiness.
B. Administer a prescribed as needed (PRN) analgesic with a sedating effect: Giving medication for sedation without a clear indication of pain or discomfort is inappropriate. Analgesics should only be administered to relieve pain, not as a substitute for a sleeping aid.
C. Explain that the effect of the medication will wear off by morning: Attempting to persuade the client to take the sleeping pill disregards his expressed preference and autonomy. Nonpharmacologic sleep promotion strategies should be prioritized to respect his wishes.
D. Encourage regular exercise before going to bed at night: Engaging in exercise immediately before bedtime can stimulate the body and increase alertness, making it more difficult to fall asleep. Exercise is beneficial earlier in the day but not recommended right before rest.
Correct Answer is D,C,B,A
Explanation
A. An adult client with an ulcer whose hemoglobin is 9.5 grams/dL: A hemoglobin of 9.5 indicates mild anemia, which is important to monitor but is not immediately life-threatening in a stable client. This assessment is lower priority compared with acute electrolyte or oxygenation issues.
B. A young adult with a history of asthma whose arterial pH is 7.48: A slightly alkalotic pH may indicate mild respiratory alkalosis. While it requires monitoring, the client is stable and not in immediate distress, making this a moderate priority.
C. An adult woman with vomiting whose potassium is 2.8 mEq/L: Hypokalemia at this level is moderate to severe and increases the risk of cardiac arrhythmias. Prompt assessment and intervention are needed, placing this client higher in priority.
D. An older adult with dizziness whose O₂ saturation is 86%: Hypoxemia is the highest priority because low oxygen saturation can rapidly compromise organ function and may be life-threatening. Immediate assessment and intervention are required.
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