A nurse accidentally sticks her hand with a needle after administering an intramuscular (IM) injection to a client. Which action should the nurse take first?
Wash the area of the puncture thoroughly with soap and water.
Notify employee health services.
Complete an incident report.
Report the incident to the charge nurse.
The Correct Answer is A
Choice A Reason:
Washing the area of the puncture thoroughly with soap and water is the first and most immediate action the nurse should take. This step helps to reduce the risk of infection by removing any potential contaminants from the puncture site. It is a crucial initial response to any needlestick injury to minimize the risk of bloodborne pathogen transmission. Proper hand hygiene is essential in preventing infections and ensuring the safety of healthcare workers.
Choice B Reason:
Notifying employee health services is an important step that should follow the initial first aid. Employee health services will provide further evaluation, testing, and follow-up care as needed. They will also guide the nurse on any necessary post-exposure prophylaxis and additional steps to take. However, this is not the first action to take immediately after the injury.
Choice C Reason:
Completing an incident report is a necessary step to document the needlestick injury. This report helps in tracking and preventing future incidents, ensuring that proper protocols are followed, and providing data for workplace safety improvements. While important, this step should be taken after the initial first aid and notification of employee health services.
Choice D Reason:
Reporting the incident to the charge nurse is also an important step in the process. The charge nurse needs to be informed about the incident to ensure that appropriate follow-up actions are taken and to provide support to the affected nurse. However, this step should come after the immediate first aid and notification of employee health services.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.
Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.
Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.
Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.
Correct Answer is A
Explanation
Choice A Reason:
A 24-hour urinary output of 380 mL indicates oliguria. Oliguria is defined as a urine output of less than 400-500 mL per day in adults. This condition can be caused by various factors, including dehydration, kidney dysfunction, or postoperative complications. Monitoring urine output is crucial for assessing kidney function and overall fluid balance, especially after major surgeries like a colon resection.
Choice B Reason:
A 24-hour urinary output of 550 mL is slightly above the threshold for oliguria. While it is still relatively low, it does not meet the strict criteria for oliguria, which is typically defined as less than 400-500 mL per day. This output suggests that the client is producing an adequate amount of urine, though it may still warrant close monitoring to ensure it does not decrease further.
Choice C Reason:
A 24-hour urinary output of 600 mL is within the normal range and does not indicate oliguria. Normal urine output for adults is generally considered to be around 800-2000 mL per day, depending on fluid intake and other factors. This output suggests that the client’s kidneys are functioning properly and that there is no immediate concern for oliguria.
Choice D Reason:
A 24-hour urinary output of 720 mL is also within the normal range and does not indicate oliguria. This output is closer to the lower end of the normal range but still suggests adequate kidney function. It is important to continue monitoring the client’s urine output to ensure it remains within a healthy range, especially after surgery.
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