A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?
Report the incident to the charge nurse.
Wash the area of the puncture thoroughly with soap and water.
Go to employee health services.
Complete an incident report.
The Correct Answer is B
Choice A rationale:
Reporting the incident to the charge nurse is important, but it's not the first action to take in this situation. The immediate concern should be addressing the potential exposure to bloodborne pathogens.
Choice B rationale:
This is the correct choice. Washing the area of the puncture thoroughly with soap and water is the first step the nurse should take after an accidental needlestick. It helps reduce the risk of infection by cleaning the wound and removing any potential contaminants.
Choice C rationale:
Going to employee health services is a valid step, but it's not the immediate action needed after an accidental needlestick. Cleaning the wound should come first.
Choice D rationale:
Completing an incident report is important for documentation purposes, but it is not the nurse's first priority in this situation. Immediate wound care takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Placing the client in airborne isolation is a priority because measles is highly contagious and spread through airborne droplets. Airborne precautions are necessary to prevent the transmission of pathogens that can remain suspended in the air for longer periods. Measles is known for its high infectivity, and isolating the client in a negative pressure room equipped with HEPA filtration can help prevent the spread of the virus to other patients and healthcare workers.
Choice B rationale:
While advising family members not to bring flowers into the room is a reasonable infection control measure, it is not the priority action in this scenario. The immediate concern is to prevent the spread of the highly contagious measles virus through airborne transmission.
Choice C rationale:
Obtaining a sputum sample for culture is not the priority action in this situation. Measles is a viral infection, and sputum cultures are typically used to identify bacterial infections. Additionally, the primary mode of transmission for measles is through airborne droplets, so preventing its spread takes precedence over obtaining a sputum sample.
Choice D rationale:
Placing the client on contact precaution is not the correct choice for managing measles. Measles is primarily transmitted through the airborne route, so airborne precautions, not contact precautions, are necessary to prevent its transmission.
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a modified Trendelenburg position is not the first intervention for a client with a deep laceration and heavy bleeding. This position involves tilting the patient with the head lower than the feet and is typically used to improve venous return in certain situations, such as hypovolemic shock. However, for a bleeding wound, the priority is to control the bleeding itself.
Choice B rationale:
Applying a tourniquet just above the wound is a drastic measure and is generally not the first intervention for controlling bleeding. Tourniquets are used when direct pressure and other methods are unsuccessful, as they can lead to complications such as tissue damage and ischemia if not used correctly.
Choice C rationale:
Starting two large-bore IV catheters is important for fluid resuscitation in cases of significant bleeding. However, it is not the first intervention. Directly controlling the bleeding takes precedence to prevent further blood loss.
Choice D rationale:
Applying pressure directly to the wound is the correct answer. This is the initial and immediate action to take when dealing with a heavily bleeding wound. Applying pressure helps to stem the bleeding by promoting clot formation and reducing blood loss. It is a vital step in managing the client's condition and preventing further deterioration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.