A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?
Report the injury to a nurse manager
Wash the affected area with soap and water
Report the needle stick to infection control department
Scrub the area with hand sanitizer for a full 2 minutes
The Correct Answer is B
A. Report the injury to a nurse manager:
While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.
B. Wash the affected area with soap and water:
This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.
C. Report the needle stick to the infection control department:
Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.
D. Scrub the area with hand sanitizer for a full 2 minutes:
Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased, strong:
A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.
B. Diminished, weaker than expected:
This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.
C. Absent, unable to palpate:
If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.
D. Bounding:
A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.
Correct Answer is A
Explanation
A. Use standard precautions in caring for all clients:
Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.
B. Place all post-surgical clients in contact isolation:
Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.
C. Order IV antibiotics for all clients with sacral pressure wounds:
Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.
D. Limit visitations to 2 people a day for each client:
While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.
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