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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:

Keep the drainage system below the level of the client’s chest at all times is correct. This measure ensures that gravity assists in the drainage of air and fluid from the pleural space, preventing backflow into the chest cavity. Keeping the drainage system below chest level maintains the negative pressure needed for effective drainage.

Choice B Reason:

Clamp the chest tube prior to transferring the client to a wheelchair is incorrect. Clamping the chest tube can lead to a buildup of air or fluid in the pleural space, potentially causing a tension pneumothorax. The chest tube should remain unclamped to allow continuous drainage.

Choice C Reason:

Empty the collection chamber prior to transport is incorrect. While it is important to monitor and manage the drainage, emptying the collection chamber is not necessary before transport. The focus should be on maintaining the integrity and function of the drainage system.

Choice D Reason:

Disconnect the chest tube from the drainage system during transport is incorrect. Disconnecting the chest tube can lead to a loss of the negative pressure system, resulting in potential complications such as pneumothorax. The chest tube should remain connected to ensure continuous drainage and maintain the negative pressure.

A. A nurse is educating a client about supplements that are effective for nausea. Which supplement should the nurse include? B. Ask the client to clench their teeth. C. Ask the client to read a Snellen chart. D. Ask the client to raise his eyebrows.

Correct Answer is B

Explanation

Choice A Reason:

Listening to the client’s speech is not a method used to assess cranial nerve V. This method is more relevant for assessing cranial nerves IX (Glossopharyngeal) and X (Vagus), which are involved in speech and swallowing.

Choice B Reason:

Clenching the teeth is a method used to assess the motor function of cranial nerve V (the trigeminal nerve). The trigeminal nerve is responsible for the movement of the muscles involved in chewing. When a client clenches their teeth, the nurse can palpate the masseter and temporal muscles to check for strength and symmetry. This helps determine if there are any abnormalities in the motor function of the trigeminal nerve.

Choice C Reason:

Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V.

Choice D Reason:

Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?

Correct Answer is A

Explanation

A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

Correct Answer is B

Explanation

A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain this type of medication works by which mechanism?

A nurse is caring for a client diagnosed with end-stage liver cancer. Which response is an indication the client is in the denial phase of the grief process?

A nurse is teaching a client who is obese and has obstructive sleep apnea on how to decrease the number of nightly apneic episodes. Which client statement indicates an understanding of the teaching?

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which muscle?

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. After stopping the transfusion, which intervention is important to complete FIRST?

Edited TextA nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?