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 A
Explanation
A. Monitoring for occult blood in urine and stool is crucial in clients with low platelet counts to detect any potential bleeding early, as they are at increased risk of bleeding due to thrombocytopenia.
B. Using a large gauge catheter may be necessary for some procedures, but it is not the priority intervention regarding the client’s current state and platelet count.
C. Removing cold and frozen foods from dietary trays does not directly address the critical concern of bleeding associated with low platelet levels.
D. While protecting bruised areas is important, it is secondary to monitoring for active bleeding, which is more critical at this stage.
Correct Answer is D
Explanation
A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.
B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.
C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.
D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall cardiovascular health. This target is aligned with current clinical guidelines for hypertension management.