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 B
This question requires knowledge of standardized blood glucose monitoring techniques. Understanding the proper sequence for obtaining a fingerstick sample is essential, specifically the rationale for removing the initial drop of blood to prevent diagnostic inaccuracies caused by localized tissue fluids and alcohol residue.
Choice A rationale: Applying direct pressure is a post-procedure step used to promote hemostasis after the sample has been collected. Doing this immediately after the prick would stop the bleeding before a sufficient sample could be obtained for the glucometer test strip.
Choice B rationale: The first drop of blood often contains high concentrations of serous fluid, interstitial fluid, or residual alcohol from the skin preparation. Wiping it away ensures that the second drop used for testing is pure capillary blood, providing a more accurate reading.
Choice C rationale: Cleaning the finger with alcohol must occur before the skin is punctured. Applying alcohol to an open wound after the prick is painful for the client and can interfere with the chemical reaction on the glucose test strip, leading to errors.
Choice D rationale: Applying the first drop directly to the test strip can lead to an inaccurate blood glucose result. Contamination from interstitial fluids or skin cleansers in the initial drop can artificially dilute or alter the glucose concentration measured by the device.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Having someone hold the weights up during transport is not recommended. Buck's traction relies on the consistent pull of the weights to maintain the proper alignment of the fracture. Holding the weights during transport would disrupt the continuous traction and could cause misalignment or exacerbate the injury. It is crucial to maintain the integrity of the traction system during transport.
Choice B reason: Preventing movement of the weights by resting them on top of the bed until the transport is completed is also not advisable. This action would negate the purpose of the traction by removing the continuous pull required to keep the fracture immobilized. Resting the weights on the bed would result in a loss of traction, potentially leading to complications in the healing process.
Choice C reason: Releasing the weights during transport and reconnecting them when the transport is completed is not appropriate. Temporarily removing the traction could cause significant discomfort to the client and disturb the alignment of the fracture. The stability provided by continuous traction is essential for the proper healing of the fracture, and interruptions can lead to adverse outcomes.
Choice D reason: Leaving the weights in place during transport is the best practice. Buck's traction is designed to provide a consistent and gentle pulling force to maintain the alignment of the fracture. The weights should remain in place to ensure the traction is effective throughout the transport process. Proper care should be taken to handle the traction system carefully and avoid any jarring movements that could impact the client's condition.
Correct Answer is A
Explanation
Choice A reason: Smoking two packs of cigarettes a day is highly significant in planning the client's rehabilitation following a myocardial infarction. Smoking is a major risk factor for cardiovascular disease, and continuing to smoke can significantly hinder recovery and increase the risk of future cardiac events. Addressing this behavior is crucial for improving the client's long-term health outcomes. Smoking cessation should be a primary focus of the rehabilitation plan, and the client should be provided with resources and support to quit smoking, such as counseling, nicotine replacement therapy, or medications.
Choice B reason: Expressing a desire to change one's lifestyle is a positive and encouraging sign. It indicates the client's motivation to adopt healthier habits, which is essential for successful rehabilitation. However, while this is important, the immediate focus should be on addressing specific risk factors, such as smoking, that have a direct and significant impact on the client's recovery and future health. The desire to change is a valuable component of the rehabilitation process, but it should be coupled with targeted interventions to address critical behaviors like smoking.
Choice C reason: Drinking 1 to 2 glasses of red wine daily may have both positive and negative health implications. Moderate alcohol consumption has been suggested to have some cardiovascular benefits, but it can also pose risks, especially if not monitored. While this information is relevant to the client's overall lifestyle, it is not as immediately critical as addressing smoking, which has a well-documented and direct impact on cardiovascular health. The client's alcohol consumption can be discussed as part of the broader lifestyle changes during rehabilitation.
Choice D reason: Walking four city blocks to work each day indicates a level of physical activity that is beneficial for cardiovascular health. Encouraging regular physical activity is an essential part of the rehabilitation process. However, compared to the impact of smoking, this information is less critical in the immediate planning of the client's rehabilitation. The focus should be on eliminating harmful behaviors like smoking, while also promoting continued and possibly increased physical activity as part of a comprehensive rehabilitation plan.
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