Nokea
The nurse is preparing to obtain a capillary blood glucose from a client. Place the following actions in the order in which they should be performed, starting from first to last.
- A. Hold the gauze on the client's finger after the specimen has been obtained.
- B. Turn the finger down to promote blood flow with gravity.
- C. Insert strip into monitor.
- D. Prick the side of the finger using the lancet.
- E. Verify and confirm that the code strip corresponds to the meter code.
- F. Disinfect the client's finger with an alcohol swab and allow it to dry.
- G. Read the client's blood glucose level on the monitor.
Correct Answer: E,F,C,D,B,A,G
Rationale: The correct order is: verify strip code (E), disinfect finger (F), insert strip (C), prick finger (D), promote blood flow (B), collect sample and apply gauze (A), read result (G). This ensures accuracy and safety.
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The nurse is preparing to administer a low-cleansing enema to a client. Which action by the nurse is appropriate during the administration of the enema?
- A. Administer the enema with the client in a supine position.
- B. Insert the enema tube 2 inches into the rectum.
- C. Use cold tap water for the enema solution.
- D. Hang the enema bag approximately 12 inches above the client's rectum.
Correct Answer: D
Rationale: Hanging the bag 12 inches above the rectum ensures proper flow. Supine position is incorrect, insertion is 3-4 inches, and cold water causes cramping.
The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
- A. Coarse tremors
- B. Intrajugular central vascular access device
- C. Wearing a wrist watch
- D. Cardiac pacemaker
Correct Answer: A
Rationale: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.
The charge nurse is reviewing room assignments and recognizes that only one private room is left. It would be appropriate to assign this room to the client with
- A. Human immunodeficiency virus (HIV).
- B. Delirium tremens who is agitated.
- C. Disseminated herpes zoster.
- D. An implantable port that is accessed.
Correct Answer: C
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a private room. HIV, delirium tremens, and accessed ports do not require isolation.
The nurse is preparing a client for a clinical breast exam by the physician. To facilitate an effective exam, the nurse should position the client
- A. Supine with arms at the side and a pillow under both knees
- B. Left lateral with the head resting on a pillow and the arm over the head
- C. Sitting forward with a pillow behind the shoulder blades with hands on the hips
- D. Supine, with the arm on the side raised behind the head, and a small pillow under the shoulder
Correct Answer: D
Rationale: Supine with the arm raised and a pillow under the shoulder flattens the breast tissue, facilitating palpation. Other positions are less effective for breast exams.
The nurse recognizes which of the following may be used as an approved client identifier? Select all that apply.
- A. first and last name
- B. date of birth
- C. telephone number
- D. admission date
- E. medical record number
- F. age
Correct Answer: A,B,E
Rationale: First and last name, date of birth, and medical record number are approved identifiers per Joint Commission standards. Telephone number, admission date, and age are not.