A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Wash the puncture site with soap and water.

Squeeze as much blood as possible from the puncture site.

Flush the puncture site with water for 5 minutes.

Begin postexposure prophylaxis the following day.

Answer and Explanation

The Correct Answer is A

Choice A reason: The first step after a needlestick injury is to wash the wound with soap and water to reduce the risk of infection. This helps to remove any pathogens that may have been introduced into the puncture site.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: Postexposure prophylaxis (PEP) should be started as soon as possible, ideally within hours and no later than 72 hours after potential exposure to HIV. Waiting until the following day could decrease the effectiveness of PEP.

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Correct Answer is B

Explanation

Choice A reason: A systemic infection would affect the entire body or multiple systems, not just the urinary tract. While a urinary tract infection can become systemic if it leads to sepsis, the scenario provided does not specify such progression.

Choice B reason: A health care-associated infection (HAI) is an infection that a patient acquires while receiving treatment for another condition within a healthcare setting. Since the infection occurred after the insertion of a urinary catheter in a hospital, it is considered an HAI.

Choice C reason: An endogenous infection originates from the host's own microbial flora. The scenario does not provide enough information to determine if the infection was caused by the client's own flora or by external sources.

Choice D reason: An exogenous infection comes from outside the body. While the urinary tract infection could be exogenous, the scenario suggests it is more likely to be health care-associated due to the timing and context of the catheter insertion.

A. Wrapping the cuff too loosely around the client's arm B. Measuring blood pressure right after the client's mealtime C. Positioning the client's arm above heart level D. Deflating the cuff too slowly

Correct Answer is C

Explanation

The correct answer is: c. Positioning the client’s arm above heart level.

Choice A: Wrapping the cuff too loosely around the client’s arm

Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.

Choice B: Measuring blood pressure right after the client’s mealtime

Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.

Choice C: Positioning the client’s arm above heart level

Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.

Choice D: Deflating the cuff too slowly

Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.

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A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

Correct Answer is B

Explanation

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is C

Explanation

Choice A: Wrapping the cuff too loosely around the client’s arm

Choice B: Measuring blood pressure right after the client’s mealtime

Choice C: Positioning the client’s arm above heart level

Choice D: Deflating the cuff too slowly

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