A guard at a prison brings an injured inmate to the facility clinic. The inmate is bleeding, and the guard asks the nurse about the inmate's HIV infection status. Which of the following actions by the nurse is appropriate?

Have the guard sign a release of information form.

Tell the guard to submit an inmate inquiry form to the warden.

Complete an incident report.

Instruct the guard to ask the inmate.

Answer and Explanation

The Correct Answer is C

A.   Having the guard sign a release of information form may not be appropriate in an emergency situation, and immediate action is needed to address the injury.
B.   Telling the guard to submit an inmate inquiry form to the warden may delay necessary medical intervention in an emergency.
C.   Completing an incident report is appropriate to document the situation and the care provided It is not necessary to disclose the inmate's HIV status in the report.

D.   Instructing the guard to ask the inmate is not a proper approach to handling a medical emergency. The nurse should focus on providing immediate care to the injured inmate.

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Correct Answer is C

Explanation

A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.

A. Choose a vein that is soft on palpation. B. Select a vein in the client's dominant arm. C. Select a site distal to previous venipuncture attempts. D. Choose the most proximal vein in the extremity.

Correct Answer is C

Explanation

A. Choosing a vein that is soft on palpation may indicate it's not suitable for IV insertion. A vein with a slight bounce or resilience is preferable.
B. Selecting a vein in the client's dominant arm is not a primary consideration. Both arms are

usually suitable, and the choice depends on factors such as accessibility and patient preference.

C. Selecting a site distal to previous venipuncture attempts reduces the risk of complications such as infiltration or infection and allows for optimal vein preservation.
D. Choosing the most proximal vein in the extremity is not typically recommended for peripheral IV insertion. Veins more distal to the body are often preferred for initial attempts, with
consideration for vein integrity and accessibility.

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A guard at a prison brings an injured inmate to the facility clinic. The inmate is bleeding, and the guard asks the nurse about the inmate's HIV infection status. Which of the following actions by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?

Correct Answer is C

Explanation

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

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