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A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Cleanse the site with an antiseptic swab.
- B. Allow the site to dry.
- C. Pierce the puncture site quickly.
- D. Squeeze the site gently to obtain a blood droplet.
- E. Apply blood to the test strip.
Correct Answer: A,B,C,D,E
Rationale: Steps are: Cleanse (A), dry (B), pierce (C), squeeze (D), and apply (E), ensuring a clean and accurate glucose reading.
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A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Set the degree of flexion and extension as tolerated by client.
- B. Pad the CPM device with a thick pillow.
- C. Place the client in high-Fowler's position.
- D. Align the client's joints with the joints on the frame.
Correct Answer: D
Rationale: Aligning the client's joints with the CPM frame ensures proper movement and prevents injury. Flexion/extension should be preset by the provider, padding isn't typically needed, and high-Fowler's position is inappropriate for this therapy.
A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
- A. Nerve damage
- B. Infection
- C. Infiltration
- D. Phlebitis
Correct Answer: C
Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue. Infection involves warmth/redness, phlebitis includes inflammation, and nerve damage affects sensation/movement.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Obtain blood pressure readings using the client's right arm.
- B. Limit range-of-motion exercises with the affected arm.
- C. Keep both arms below the level of the client's heart.
- D. Use the client's left arm to obtain blood samples.
- E. Elevate the right arm.
- F. Apply compression bandages.
- G. Avoid tight clothing.
Correct Answer: D
Rationale: Using the left arm prevents trauma to the right side, reducing lymphedema risk; BP on the affected arm increases risk.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- D. Platelets 60,000/mm³ (150,000 to 400,000/mm³)
Correct Answer: D
Rationale: Liver biopsy carries bleeding risk due to the organ's vascularity, so clotting ability is critical. Platelets at 60,000/mm³ are severely low (normal 150,000-400,000/mm³), increasing hemorrhage risk post-procedure. Bilirubin (1.0 mg/dL) and AST (34 units/L) are within normal limits, reflecting liver function but not bleeding tendency. Ammonia (55 mcg/dL) is normal, relevant to encephalopathy, not biopsy safety. Thrombocytopenia below 100,000/mm³ often prompts transfusion or delay per procedural protocols, as platelets are vital for hemostasis. Reporting this to the provider ensures risk assessment potentially canceling or modifying the biopsy prioritizing patient safety over proceeding with normal liver markers, making it the critical value to escalate.
A nurse in a provider's office is assisting in the care of a client. Complete the following sentence: The first action the nurse should take is to reinforce education about...
- A. nutritional supplements followed by collecting data about nutritional intake.
- B. increasing fluid intake followed by monitoring respiratory rate.
- C. checking blood pressure followed by administering oxygen.
- D. assessing fatigue followed by ordering a chest X-ray.
Correct Answer: A
Rationale: The client's generalized weakness, fatigue, shortness of breath, and pale mucous membranes (Exhibit 1) with a vegan diet suggest anemia, likely iron deficiency. Reinforcing education about nutritional supplements (e.g., iron, Bâ‚â‚‚) addresses potential deficiencies vegans risk low iron and Bâ‚â‚‚ without fortified foods while collecting intake data identifies dietary gaps, guiding tailored therapy. Increasing fluids and monitoring respiration might help hydration or respiratory distress, but anemia is the primary issue, not fluid status. Checking blood pressure (132/60 to 102/50 mm Hg) shows orthostasis, a symptom, not the cause oxygen isn't indicated with 94% saturation. Assessing fatigue is ongoing, but a chest X-ray targets lungs, not anemia. Education and data collection tackle the root nutritional cause, aligning with holistic care and prevention, making it the nurse's first action.