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?
Select another finger.
Apply pressure to the site.
Assess radial pulse volume.
Collect the blood sample.
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. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.
B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.
C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.
D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.
Correct Answer is C
Explanation
A. Immediately after the patient has been medicated for pain.
While pain relief may help, education should be conducted when the patient is alert and comfortable, not immediately after pain medication when they may be drowsy.
B. The last thing in the evening, after visitors have left, before bedtime. Education right before bedtime may not be effective if the patient is tired, as retention and attention may be reduced.
C. When the patient is comfortable and receptive to the patient education.
Teaching should occur when the patient is comfortable, alert, and receptive to ensure they can retain and understand the information.
D. Just before the patient is discharged, so the information is current.
Waiting until discharge could overwhelm the patient, and they may not have time to ask questions or clarify information.