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 C
Explanation
A. Do not let the patient know you are counting their respirations:
This is not directly related to obtaining vital signs and is not a critical factor for a patient with a low platelet count.
B. Let the patient rest for 5 minutes before you measure their blood pressure:
Allowing the patient to rest for a few minutes before measuring blood pressure is a good practice but may not be as critical as other considerations in a patient with a low platelet count.
C. Do not measure the patient’s temperature rectally:
Patients with low platelet counts are at an increased risk of bleeding. Rectal temperatures can be invasive and carry a risk of mucosal injury, making them less advisable in patients with bleeding risks.
D. Count the patient’s radial pulse for 30 seconds and multiply it by 2:
Counting the radial pulse is a suitable method for assessing heart rate in a patient at risk for bleeding. However, rectal temperature measurement should be avoided due to the risk of mucosal injury.
Correct Answer is B
Explanation
A. Evaluation:
Both RNs and LPNs engage in the evaluation step of the nursing process. It involves assessing the effectiveness of the care plan and determining whether the desired outcomes have been achieved.
B. Analysis:
The analysis step involves a deeper level of critical thinking and problem-solving. It often includes a more comprehensive examination and interpretation of assessment data to develop the nursing diagnosis, a step that typically falls within the scope of practice for RNs.
C. Implementation:
Both RNs and LPNs are involved in implementing the care plan, which includes carrying out nursing interventions according to the established plan of care.
D. Planning:
Both RNs and LPNs participate in the planning phase, which involves setting goals, establishing priorities, and creating a care plan tailored to the patient's needs.
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.