A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

Activate the device immediately after injection.

Remove the safety device before disposal.

Make sure the needle retracts into the barrel of the syringe.

Pull the plastic sheath over the needle.

Answer and Explanation

The Correct Answer is A

A.   After administering the injection, activating the passive needle-safety device involves a mechanism where the safety feature automatically engages. This can include a shield that covers the needle or a mechanism that retracts the needle into the syringe or device. It's crucial to activate this immediately after injection to prevent accidental needlestick injuries.
B.   The safety device, once activated, should remain in place and intact on the needle until it is safely disposed of in an appropriate sharps container. Removing the safety device before disposal would expose healthcare workers to potential needlestick injuries.
C.   There is no need to make sure the needle retracts into the barrel of the syringe, as the safety device is designed to cover the needle after use.
D.   While some devices have a plastic sheath or shield that covers the needle before and after use, the primary action for a passive device is to activate the safety feature that automatically covers or retracts the needle post-injection. Pulling a sheath over the needle manually is more typical for active safety devices or conventional needles with manual sheath covers.

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Correct Answer is D

Explanation

A. Indwelling urinary catheters are associated with an increased risk of urinary tract infections (UTIs) and other complications, including skin irritation and breakdown around the catheter site. Routine use of indwelling catheters is not recommended for managing routine urinary incontinence due to these risks.

B. Using hot water or harsh cleansers can strip the skin of its natural oils and lead to further irritation and breakdown. Instead, gentle cleansing with mild soap and warm water is recommended after each episode of incontinence to remove urine and prevent skin irritation. Patting the skin dry rather than rubbing can also help prevent damage to the skin barrier.
C. Regular skin assessment is crucial in clients with urinary incontinence to identify early signs of skin breakdown. Checking the skin every 8 hours may not be frequent enough, particularly if the client is incontinent frequently. More frequent assessment, ideally after each episode of incontinence or at least every 2-4 hours, is recommended to promptly identify and address any skin issues.
D. Applying a moisture barrier ointment or cream to the perineal area and any areas prone to moisture can help protect the skin from urine and fecal exposure. These products create a barrier that prevents direct contact of urine with the skin, reducing the risk of irritation and breakdown. Regular application, especially after cleansing and as needed throughout the day, can help maintain skin integrity.

A. Reposition the client at least every 2 hr. B. Keep the head of the bed elevated. C. Keep the client's skin moist. D. Massage the client's bony prominences.

Correct Answer is A

Explanation

A. Repositioning the client regularly is a critical measure to prevent pressure ulcers. This helps relieve pressure on vulnerable areas of the body and improves circulation. Turning the client every 2 hours is a common guideline to prevent prolonged pressure on any one area.
B. Keeping the head of the bed elevated continuously is not recommended as it can increase shear and friction, leading to skin breakdown.
C. Keeping the client's skin moisturized is important for maintaining skin integrity, but excessive moisture can increase the risk of skin breakdown, especially in areas susceptible to pressure ulcers. The nurse should aim to keep the skin clean, dry, and free from excessive moisture to prevent maceration.
D. Massaging bony prominences is not recommended as a preventive measure for pressure ulcers. In fact, massaging these areas can increase the risk of tissue damage due to friction and shearing forces. The focus should be on relieving pressure through proper positioning and support surfaces rather than massage.

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A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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