When obtaining a fingerstick blood sugar, the practical nurse (PN) uses the lancet to prick the client's finger. After observing that a drop of blood is visible on the finger, which action should the PN take?
Apply direct pressure over the area that is bleeding.
Wipe off the drop of blood with a gauze pad.
Clean the finger with an alcohol prep pad.
Apply the drop of blood to the test strip.
The Correct Answer is D
Choice A reason: Applying direct pressure over the area that is bleeding is a general first aid measure to stop bleeding. However, in the context of obtaining a fingerstick blood sugar, this action is not the immediate next step. The objective of the fingerstick is to obtain a sample of blood for testing blood glucose levels. Applying pressure would stop the flow of blood, making it difficult to obtain a sufficient sample for the test.
Choice B reason: Wiping off the drop of blood with a gauze pad is not recommended after pricking the finger for a blood glucose test. Removing the initial drop of blood could result in the need to squeeze the finger again, potentially causing hemolysis (breaking of blood cells) and leading to an inaccurate reading. It is important to use the initial drop of blood for the test to ensure accurate results.
Choice C reason: Cleaning the finger with an alcohol prep pad before pricking is a standard step to ensure that the area is free from contaminants and to prevent infection. However, doing this after the drop of blood is visible is unnecessary and can interfere with the sample. Alcohol residue can affect the accuracy of the blood glucose reading. Therefore, cleaning should be done prior to pricking, not after the blood is obtained.
Choice D reason: Applying the drop of blood to the test strip is the correct action to take. Once the drop of blood is visible, it should be applied to the test strip immediately to obtain a blood glucose reading. This ensures that the sample is fresh and uncontaminated, providing an accurate measurement of the client's blood sugar levels. This step is essential for effective monitoring and management of diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Driving a car is an activity that requires physical and mental focus, which can be impaired following surgery. The client recovering from a transurethral prostatectomy might experience discomfort, pain, or the effects of anesthesia, which could affect their ability to drive safely. Additionally, there is a risk of increased pressure on the surgical site while sitting for prolonged periods, which can impact the healing process. Limiting this activity until after the first postoperative visit ensures that the healthcare provider can assess the client's recovery and provide appropriate guidance on when it is safe to resume driving.
Choice B reason: Eating high-fiber foods is generally encouraged to prevent constipation, which is a common issue post-surgery. Fiber helps maintain regular bowel movements and can reduce the strain during defecation. This is beneficial for clients recovering from a transurethral prostatectomy as straining can increase pressure on the surgical site. Therefore, there is no need to limit the intake of high-fiber foods; rather, it should be reinforced as a positive dietary habit during the recovery period.
Choice C reason: Kegel exercises are recommended to strengthen the pelvic floor muscles, which can aid in improving urinary control post-surgery. These exercises are an integral part of the recovery process for clients undergoing prostate surgery and can significantly enhance bladder function. Thus, Kegel exercises should not be limited but should be encouraged as part of the client's postoperative care plan.
Choice D reason: Walking around the house is a low-impact activity that can promote circulation and prevent complications such as deep vein thrombosis (DVT). It also helps in maintaining overall mobility and can aid in the recovery process. Limiting such light physical activity is unnecessary, as it can have several benefits for the client during the postoperative period. Encouraging gentle movement is generally advantageous for recovery.
Correct Answer is A
Explanation
Choice A reason: Hematemesis, or vomiting of blood, is a critical symptom to monitor in a client with esophageal varices. Esophageal varices are enlarged veins in the esophagus that can rupture and bleed due to increased pressure in the portal venous system, a common complication of cirrhosis. Hematemesis indicates a potentially life-threatening variceal bleed that requires immediate medical intervention. Reporting this finding promptly ensures that the healthcare team can take swift action to manage the bleeding and stabilize the client.
Choice B reason: Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. While it is important to address nutritional concerns, anorexia does not directly indicate a life-threatening complication like variceal bleeding. Monitoring for anorexia is essential for overall health and nutritional support, but it is not the most immediate concern in this scenario.
Choice C reason: Clay-colored stools can indicate a lack of bile in the stool, which may occur due to biliary obstruction or impaired bile flow. While this finding is significant and requires attention, it is not as urgent as hematemesis in the context of esophageal varices. Clay-colored stools may suggest other complications related to liver function but do not indicate an immediate life-threatening situation.
Choice D reason: Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders. While this finding is important to monitor, it is not directly related to esophageal varices or their complications. The primary concern with esophageal varices is the risk of bleeding, which is best indicated by hematemesis.
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