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Questions and Answers
A nurse is teaching assistive personnel (AP) how to perform capillary blood glucose testing. Which instruction is most important to emphasize regarding infection control?
A nurse is teaching assistive personnel (AP) how to perform capillary blood glucose testing. Which instruction is most important to emphasize regarding infection control?
- Use a new lancet for each client. (correct)
- Ensure the client washes their hands with soap and water prior to the test.
- Clean the glucose meter with alcohol after each use.
- Wear sterile gloves for the procedure.
A client's capillary blood glucose reading is critically low. After confirming the result, which action should the nurse prioritize?
A client's capillary blood glucose reading is critically low. After confirming the result, which action should the nurse prioritize?
- Immediately administer oral glucose if the client is conscious and able to swallow. (correct)
- Notify the provider after rechecking the glucose level in 15 minutes.
- Recheck the glucose level using a different glucose meter.
- Document the result and continue with routine monitoring.
The nurse is performing a capillary blood glucose test on a client with significant peripheral edema in both hands. What is the most appropriate alternate site for obtaining the sample?
The nurse is performing a capillary blood glucose test on a client with significant peripheral edema in both hands. What is the most appropriate alternate site for obtaining the sample?
- The earlobe. (correct)
- The palmar surface of the hand.
- The anterior forearm.
- The plantar surface of the foot.
When performing a capillary blood glucose test on an infant, which anatomical site is most appropriate to prevent potential injury?
When performing a capillary blood glucose test on an infant, which anatomical site is most appropriate to prevent potential injury?
A nurse is having difficulty obtaining an adequate drop of blood after performing a finger stick. Which of the following techniques would be most appropriate to improve blood flow?
A nurse is having difficulty obtaining an adequate drop of blood after performing a finger stick. Which of the following techniques would be most appropriate to improve blood flow?
A nurse is reviewing a client's medication list and notes the client is taking a high dose of aspirin daily. How might this affect the capillary blood glucose testing procedure or results?
A nurse is reviewing a client's medication list and notes the client is taking a high dose of aspirin daily. How might this affect the capillary blood glucose testing procedure or results?
A nurse is performing a capillary blood glucose test on a client who reports a latex allergy. Which of the following modifications is most important?
A nurse is performing a capillary blood glucose test on a client who reports a latex allergy. Which of the following modifications is most important?
The nurse is teaching a client how to perform capillary blood glucose testing at home. What should the nurse emphasize regarding the disposal of used lancets?
The nurse is teaching a client how to perform capillary blood glucose testing at home. What should the nurse emphasize regarding the disposal of used lancets?
A client's capillary blood glucose reading is significantly higher than their usual range. After verifying the result, what is the most appropriate initial nursing action?
A client's capillary blood glucose reading is significantly higher than their usual range. After verifying the result, what is the most appropriate initial nursing action?
A nurse is preparing to perform a capillary blood glucose test on a client receiving anticoagulant therapy. What modification to the procedure is most important?
A nurse is preparing to perform a capillary blood glucose test on a client receiving anticoagulant therapy. What modification to the procedure is most important?
The nurse delegates the task of capillary blood glucose testing to an assistive personnel (AP). Which instruction is most important to provide to the AP?
The nurse delegates the task of capillary blood glucose testing to an assistive personnel (AP). Which instruction is most important to provide to the AP?
A nurse obtains a capillary blood glucose reading that does not correlate with the client's current clinical presentation. What is the most appropriate next step?
A nurse obtains a capillary blood glucose reading that does not correlate with the client's current clinical presentation. What is the most appropriate next step?
The nurse is performing capillary blood glucose testing on a client with a history of poor peripheral circulation. What should the nurse consider when selecting a puncture site?
The nurse is performing capillary blood glucose testing on a client with a history of poor peripheral circulation. What should the nurse consider when selecting a puncture site?
A nurse is providing discharge instructions to a client who will be performing capillary blood glucose testing at home. Which statement by the client indicates a need for further teaching?
A nurse is providing discharge instructions to a client who will be performing capillary blood glucose testing at home. Which statement by the client indicates a need for further teaching?
A nurse is preparing to use a new glucose meter. What is the most important step to ensure accurate results?
A nurse is preparing to use a new glucose meter. What is the most important step to ensure accurate results?
A nurse notes that the client's hands are cold and clammy. How should the nurse modify the procedure for capillary blood glucose testing?
A nurse notes that the client's hands are cold and clammy. How should the nurse modify the procedure for capillary blood glucose testing?
Which statement accurately describes the rationale for confirming a client's allergy status prior to performing a capillary blood glucose test?
Which statement accurately describes the rationale for confirming a client's allergy status prior to performing a capillary blood glucose test?
The results of a client's capillary blood glucose test are flagged as critically high by the glucose meter. What is the nurse's next best action?
The results of a client's capillary blood glucose test are flagged as critically high by the glucose meter. What is the nurse's next best action?
What is the primary rationale for raising the bed to a comfortable height before performing a capillary blood glucose test?
What is the primary rationale for raising the bed to a comfortable height before performing a capillary blood glucose test?
A client questions the necessity of performing a capillary blood glucose test, stating they feel fine. What is the most appropriate response from the nurse?
A client questions the necessity of performing a capillary blood glucose test, stating they feel fine. What is the most appropriate response from the nurse?
A nurse notes that the date is expired on the package of test strips. The nurse should anticipate what consequence if the expired strips are used?
A nurse notes that the date is expired on the package of test strips. The nurse should anticipate what consequence if the expired strips are used?
Which of the following is the most accurate description of the proper technique for applying a drop of blood to a glucose test strip?
Which of the following is the most accurate description of the proper technique for applying a drop of blood to a glucose test strip?
A nurse is reviewing documentation guidelines for capillary blood glucose testing. Which of the following elements is most important to include in the client's medical record?
A nurse is reviewing documentation guidelines for capillary blood glucose testing. Which of the following elements is most important to include in the client's medical record?
A nurse is preparing to perform capillary blood glucose testing on a client who has a history of bleeding disorders. What is the most important action?
A nurse is preparing to perform capillary blood glucose testing on a client who has a history of bleeding disorders. What is the most important action?
A nurse is teaching a client about factors that can affect capillary blood glucose results. Which factor should the nurse emphasize as potentially causing a falsely elevated reading?
A nurse is teaching a client about factors that can affect capillary blood glucose results. Which factor should the nurse emphasize as potentially causing a falsely elevated reading?
A nurse is performing point-of-care testing in a rural setting with limited resources. The facility does not have sharps containers. What immediate alternative should the nurse implement for safe lancet disposal?
A nurse is performing point-of-care testing in a rural setting with limited resources. The facility does not have sharps containers. What immediate alternative should the nurse implement for safe lancet disposal?
During a home visit, a client expresses anxiety about performing capillary blood glucose testing due to pain. What strategy should the nurse suggest to minimize discomfort?
During a home visit, a client expresses anxiety about performing capillary blood glucose testing due to pain. What strategy should the nurse suggest to minimize discomfort?
A nurse is reviewing the steps for capillary blood glucose testing with a newly diagnosed diabetic client. Which of the following actions, if performed by the client, indicates a need for further teaching?
A nurse is reviewing the steps for capillary blood glucose testing with a newly diagnosed diabetic client. Which of the following actions, if performed by the client, indicates a need for further teaching?
The nurse is performing a capillary blood glucose test on a client in isolation for Clostridium difficile. Which of the following modifications to the procedure is most important?
The nurse is performing a capillary blood glucose test on a client in isolation for Clostridium difficile. Which of the following modifications to the procedure is most important?
A nurse is teaching a client how to interpret capillary blood glucose results. The client asks what to do if the reading is consistently higher than the target range. What is the most appropriate initial action?
A nurse is teaching a client how to interpret capillary blood glucose results. The client asks what to do if the reading is consistently higher than the target range. What is the most appropriate initial action?
A client reports consistently elevated blood glucose levels in the morning, despite adhering to their prescribed diet and medication regimen. Which of the following should the nurse suspect as a potential cause?
A client reports consistently elevated blood glucose levels in the morning, despite adhering to their prescribed diet and medication regimen. Which of the following should the nurse suspect as a potential cause?
A nurse performing capillary blood glucose testing on a client in a long-term care facility notices that the client report they feel fine during a routine check. The client asks why the test needs to be performed. What is the nurse's best response?
A nurse performing capillary blood glucose testing on a client in a long-term care facility notices that the client report they feel fine during a routine check. The client asks why the test needs to be performed. What is the nurse's best response?
Flashcards
Capillary Blood Glucose Testing
Capillary Blood Glucose Testing
A superficial skin puncture to monitor blood glucose using a portable meter.
Delegation of Capillary Blood Glucose Testing
Delegation of Capillary Blood Glucose Testing
Licensed nurses (RN/PN) and trained assistive personnel (AP) can perform this skill when the client is in stable condition and following facility protocol.
Safety Considerations
Safety Considerations
To prevent allergic reactions, infections and ensure correct procedure on the correct patient.
Supplies Needed
Supplies Needed
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Reviewing Client's Medical Record
Reviewing Client's Medical Record
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Signs of Altered Blood Glucose
Signs of Altered Blood Glucose
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Preferred Testing Sites
Preferred Testing Sites
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Allowing Antiseptic to Dry
Allowing Antiseptic to Dry
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Avoid Excessive Pressure
Avoid Excessive Pressure
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Filling the Test Strip
Filling the Test Strip
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Expected Glucose Range (Adults)
Expected Glucose Range (Adults)
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Impaired Peripheral Perfusion
Impaired Peripheral Perfusion
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Infant Testing Considerations
Infant Testing Considerations
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Repeating Glucose Sample
Repeating Glucose Sample
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Warming the Site
Warming the Site
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Documentation
Documentation
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Study Notes
- Obtaining a capillary blood sample involves a superficial skin puncture to monitor blood glucose levels using a portable glucose meter.
- An RN can delegate this task to a PN or trained AP if the client is stable and per facility policy.
Safety Considerations
- Check for client allergies to prevent allergic reactions.
- Verify client identification to ensure the correct procedure on the correct client.
- Use standard and infection control precautions to prevent transmission of infectious organisms.
Equipment Needed
- Nonsterile gloves and PPE (if indicated) prevent contact with blood/body fluids.
- Antiseptic wipes clean the skin to prevent infection.
- Cotton ball/gauze applies pressure post-puncture to stop bleeding.
- Adhesive bandage covers/protects the puncture site (optional).
- Skin puncture device (lancet) obtains the blood sample.
- Glucose meter tests the sample.
- Glucose test strips collect the sample for meter evaluation.
Step-by-Step Procedure
Assessment/Data Collection
- Review allergies, medical history, medications, lab values, and blood glucose monitoring prescription.
- Low platelets or medications affecting clotting may prolong bleeding.
- Trends in blood glucose results provide information about expected values.
- Prescription dictates frequency of blood glucose assessment.
- Identify client using two identifiers and verify allergy status.
- Assess skin integrity; edges of fingers/earlobes are ideal (vascular, intact skin, no bruising).
- Evaluate for alterations in blood glucose levels (sweating, shaking, confusion for low; increased thirst/urination for high).
Planning
- Gather all supplies ensuring they are clean and functioning.
Implementation
- Provide privacy to maintain client confidentiality.
- Introduce yourself to promote a therapeutic relationship.
- Perform hand hygiene and apply PPE to prevent infection.
- Educate client to decrease anxiety and promote understanding.
- Prepare the glucose monitor per manufacturer's instructions.
- Don clean gloves and adhere to standard precautions.
- Raise the bed for proper body mechanics.
- Cleanse the testing area with antiseptic and allow to dry for effectiveness.
- Remove the lancet cap to maintain sterility.
- Place the lancet firmly against the outer edge to ensure adequate puncture.
- Activate the lancet per instructions.
- Apply gentle pressure to obtain a large drop without causing hemolysis.
- Cover the test strip area with blood and insert into the meter.
- Apply pressure to the puncture site and bandage if needed.
- Turn off the glucose monitor and dispose of the test strip for safety.
- Ensure client safety before leaving the room (call light, bed position, reach).
Assessment/Data Collection
- Determine if the glucose level is within the expected range (generally 70-140 mg/dL for adults).
Implementation
- Discuss findings with the client.
Client Considerations
- Impaired peripheral perfusion may require alternate sites like the earlobe. Extremity with decreased perfusion may result in inaccurate glucose reading.
- In infants, use outer aspects of the heel to avoid nerve/bone injury.
Interventions for Unexpected Outcomes
- Repeat the test if results don't match clinical presentation. A repeat verifies an accurate result or may warrant a venous sample for the lab.
- Warm the site if cool to ensure good blood flow and adequate sample size. Prevents the need to repeat a fingerstick.
Documentation
- Document date, time, location, glucose level, and interventions in the client's record.
- Timely documentation provides access to data for the healthcare team.
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