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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Palpation:

Palpation involves using the hands to feel for tenderness, masses, or abnormalities in the abdomen. It is typically performed after auscultation. This helps prevent stimulating bowel activity before listening to bowel sounds.

B. The order does not matter:

In the context of abdominal assessment, the order does matter. Following a specific sequence, such as inspection, auscultation, palpation, and then percussion, is recommended to ensure a comprehensive and accurate assessment.

C. Auscultation:

Auscultation involves listening to bowel sounds using a stethoscope. It is the next step after inspection. Listening to bowel sounds before palpation helps avoid artificially stimulating bowel activity.

D. Percussion:

Percussion involves tapping the abdomen to assess for the presence of fluid or air. While less commonly performed in routine abdominal assessments, it is usually the last technique after inspection, auscultation, and palpation.

A. Tie it to the bed frame with a quick release knot B. Strap the restraint with a square knot to the head of the bed C. Use a quick release knot to tie the restraint to the side rail D. Assist with range of motion at least every 3 hours

Correct Answer is A

Explanation

A. Tie it to the bed frame with a quick release knot.This option is correct because securing the restraint to the bed frame ensures that the client cannot easily remove it, while a quick release knot allows for rapid removal in case of an emergency.

B. Strap the restraint with a square knot to the head of the bed.While a square knot may be secure, it is not considered a quick-release method, which is essential for the safety of the client.

C. Use a quick release knot to tie the restraint to the side rail.Tying a restraint to the side rail can pose a risk because if the side rail is lowered, it may create a situation where the restraint is loose or ineffective. It is safer to secure it to the bed frame instead.

D. Assist with range of motion at least every 3 hours.While providing range of motion is important to prevent complications from immobility, it does not address how to secure the restraint itself. Regular assessments and range of motion exercises should be part of the overall care plan but are not directly related to securing the restraint.

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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?

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During a physical assessment a nurse inspects a patient’s abdomen. What assessment technique would the nurse perform next?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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?

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