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. While having the client sign permits is important, it is not the priority action in this situation.
B. Notifying the healthcare provider about the client's current heparin therapy is critical, as it may influence the timing of surgery and the risk of excessive bleeding during and after the procedure.
C. While explaining the potential for bleeding is important, it should occur after ensuring the surgical team is aware of the heparin use.
D. Observing injection sites for bruising is relevant but does not address the immediate concern regarding heparin use and potential bleeding during surgery.
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.