Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is using a glucometer to measure a client's capillary blood glucose level.
Which of the following actions should the nurse take?
A. Keep the finger in a dependent position.
Keeping the finger in a dependent position (lower than the heart) helps promote blood flow to the fingertips, making it easier to obtain a blood sample. This position can facilitate the formation of a blood drop, improving the chances of obtaining an adequate sample for testing.
B. Wear sterile gloves.
Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. Clean, non-sterile gloves are generally sufficient for this procedure. However, the nurse should perform proper hand hygiene to minimize the risk of contamination.
C. Select the central tip of a finger
The central tip of the finger is more sensitive, and choosing this area may cause greater discomfort for the client. The sides of the fingertips are often preferred for capillary blood glucose testing as they have a good blood supply and are less sensitive.
D. Test the first drop of blood that forms after the puncture.
The initial drop may contain tissue fluid or contaminants from the puncture site, so it is important to use the first drop to obtain a representative blood sample. This step contributes to the accuracy of the blood glucose measurement.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
A. Keep the finger in a dependent position:
- Keeping the finger in a dependent position (lower than the heart) helps promote blood flow to the fingertips, making it easier to obtain a blood sample. This position can facilitate the formation of a blood drop, improving the chances of obtaining an adequate sample for testing.
B. Wear sterile gloves:
- Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. Clean, non-sterile gloves are generally sufficient for this procedure. However, the nurse should perform proper hand hygiene to minimize the risk of contamination.
C. Select the central tip of a finger:
- The central tip of the finger is more sensitive, and choosing this area may cause greater discomfort for the client. The sides of the fingertips are often preferred for capillary blood glucose testing as they have a good blood supply and are less sensitive.
D. Test the first drop of blood that forms after the puncture:
- The initial drop may contain tissue fluid or contaminants from the puncture site, so it is important to use the first drop to obtain a representative blood sample. This step contributes to the accuracy of the blood glucose measurement.
Similar Questions
A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?
A. Consume soft, bland foods.
Consume soft, bland foods. The client with stomatitis should avoid spicy, acidic, or rough foods that can irritate the inflamed mucous membranes of the mouth.
B. Eat foods high in vitamin B
C. Use lemon glycerin swabs
D. Rinse the mouth with an alcohol-based mouthwash.
Full Explanation
The correct answer is A. Consume soft, bland foods. The client with stomatitis should avoid spicy, acidic, or rough foods that can irritate the inflamed mucous membranes of the mouth.
A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take?
A. Administer the client's formula at room temperature.
Administer the client's formula at room temperature. The nurse should administer the formula at room temperature to reduce gastrointestinal motility and prevent diarrhea.
B. Provide the client with low-calorie formula.
C. Increase the rate of the client's feeding.
D. Switch the client to a formula containing less protein
Full Explanation
The correct answer is A. Administer the client's formula at room temperature. The nurse should administer the formula at room temperature to reduce gastrointestinal motility and prevent diarrhea.
A nurse is preparing to provide tracheostomy care for a client.
Which of the following actions should the nurse plan to take?
A. Cleanse the inner cannula with isopropyl alcohol
Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.
B. Prepare sterile supplies after removing the inner cannula.
Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.
C. Clean the stoma using an inward to outward circular motion
Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.
D. Ensure at least three finger widths of space under tracheostomy ties.
Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.
Full Explanation
The correct answer is choice C. Clean the stoma using an inward to outward circular motion.
Choice A rationale:
Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.
Choice B rationale:
Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.
Choice C rationale:
Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.
Choice D rationale:
Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.