A nurse is inserting an intravenous catheter for a client which results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
Carefully remove the gloves and follow with hand hygiene.
Prepare an incident report.
Ask the client to undergo a blood test.
Wash the gloved hands and then throw the gloves away.
The Correct Answer is A
Rationale:
A. Carefully remove the gloves and follow with hand hygiene is correct because gloves are considered personal protective equipment (PPE) that protect the nurse from exposure to bloodborne pathogens. Once contaminated, gloves should be removed properly to prevent further contamination, followed immediately by hand hygiene to ensure any residual microorganisms on the skin are removed. This follows standard infection control protocols.
B. Prepare an incident report is incorrect because a blood spill on gloves does not require an incident report if no exposure occurred and proper procedures were followed. Incident reports are reserved for needlestick injuries or other breaches in standard precautions that pose risk of infection.
C. Ask the client to undergo a blood test is incorrect because the client has no documented infection, and a blood test is not warranted. Testing the client would be unnecessary, invasive, and not indicated by standard precautions.
D. Wash the gloved hands and then throw the gloves away is incorrect because washing gloves is ineffective in removing pathogens and does not replace proper hand hygiene. Contaminated gloves must be discarded and hands washed thoroughly after removal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Discontinue the IV is correct because the first and most important action when infiltration occurs is to stop the IV infusion and remove the catheter. Continuing the infusion can increase tissue damage, swelling, and discomfort, especially if the fluid is irritating to the tissues.
B. Slow the infusion rate is incorrect because slowing the infusion does not stop the fluid from leaking into the surrounding tissue. The IV must be removed to prevent further infiltration and potential tissue injury.
C. Elevate the extremity after stopping the IV is incorrect as the first action because while elevation can help reduce swelling, it is secondary to discontinuing the IV, which addresses the root cause.
D. Apply a warm compress is incorrect as the first step because compresses are only applied after the IV is discontinued to promote absorption of infiltrated fluid and relief of discomfort. Cold compresses may be used for certain types of infiltration depending on the fluid.
Correct Answer is A
Explanation
Rationale:
A. Stop the IV infusion immediately and contact the provider is correct. Warmth, pain, and possible redness at the IV site are classic signs of phlebitis, which can progress to infection or thrombophlebitis if not addressed promptly. Stopping the IV prevents further irritation or medication infusion into the inflamed vein, and notifying the provider allows for appropriate interventions, such as removing the catheter and prescribing treatment.
B. Place the affected extremity below the level of the client's heart is incorrect because elevation, not lowering, is used for infiltration to reduce swelling. Placing the extremity lower does not treat phlebitis and may worsen discomfort.
C. Place a pressure dressing over the IV site is incorrect because pressure dressings are used for bleeding control, not for phlebitis. Applying pressure over an inflamed vein may increase pain and further irritate the tissue.
D. Apply a warm compress to the IV site is partially correct as a supportive measure for comfort and to promote blood flow and healing, but it is secondary to stopping the infusion. Continuing the IV while applying a warm compress would worsen the irritation.
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.