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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?

A.

Select another finger.

B.

Apply pressure to the site.

C.

Assess radial pulse volume.

D.

Collect the blood sample.

Answer and Explanation

The Correct Answer is A

A. Selecting another finger is the best action to prevent discomfort and ensure an accurate blood sample. The reddened and engorged tip may indicate that milking the finger caused bruising or altered blood flow, which can affect the glucose reading.  

 

B. Applying pressure to the site may be appropriate after collecting a sample, but it does not address the issue of obtaining an accurate sample from an engorged finger.  

 

C. Assessing radial pulse volume is not relevant in this situation and does not address the problem at hand.  

 

D. Collecting the blood sample from a reddened and engorged finger could yield an inaccurate result, so it is better to select a different finger.  


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Correct Answer is B

Explanation

A. While elevated creatinine and BUN are important indicators of kidney function, in the diuretic phase, the focus shifts to monitoring for complications, particularly fluid and electrolyte balance.

B. Hypovolemia can occur due to excessive diuresis during the diuretic phase, which can lead to significant cardiovascular effects, including ECG changes related to electrolyte imbalances, particularly potassium levels.

C. Monitoring for uremic irritation is important but less critical than monitoring for hypovolemia and ECG changes that can lead to acute complications.

D. While monitoring for side effects of TPN is relevant, it is not the priority in the context of AKI transitioning phases where fluid and electrolyte balance are paramount.

Correct Answer is A

Explanation

A. A headache that worsens upon sitting up is characteristic of a post-lumbar puncture headache, indicating a potential complication related to cerebrospinal fluid leakage.

B. Pain in the lower back after the procedure can be normal and does not necessarily indicate a complication.

C. Nausea and vomiting can occur but are not specific indicators of a complication following a lumbar puncture.

D. Sore throat when swallowing and talking is not typically associated with lumbar puncture complications and may relate to other causes such as anxiety or dehydration.

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