A nurse is teaching a newly licensed nurse about preventing puncture injuries, Which of the following instructions should the nurse include?

Break needles on syringes before disposal

Use two hands to recap a needle after administering a medication

Dispose of used razors in wastebaskets.

Replace sharps containers when they are 3/4 full.

Answer and Explanation

The Correct Answer is D

A) "Break needles on syringes before disposal":
Breaking needles before disposal is not a safe practice because it increases the risk of injury to staff during disposal. Needles should be disposed of intact in designated sharps containers to prevent injury. Tampering with used needles or syringes could expose staff to bloodborne pathogens.

B) "Use two hands to recap a needle after administering a medication":
The use of two hands to recap a needle is a high-risk behavior and should be avoided. The proper procedure is to never recap a needle after use. If recapping is absolutely necessary, a one-handed technique using the cap or a mechanical device should be employed to reduce the risk of needlestick injuries. The best practice is to dispose of the needle immediately in a sharps container.

C) "Dispose of used razors in wastebaskets":
Used razors should never be disposed of in wastebaskets, as this poses a significant risk of injury to waste management personnel. Razors, like needles and other sharp objects, should be placed in a designated sharps container. These containers are puncture-resistant and provide a safe environment for the disposal of used sharp items.

D) "Replace sharps containers when they are 3/4 full":
Sharps containers should be replaced when they are 3/4 full to prevent overfilling, which increases the risk of needlestick injuries. Overfilled containers can also make it difficult to dispose of new sharps safely. It is essential to follow institutional guidelines for the proper disposal of sharps and ensure that containers are replaced in a timely manner to maintain a safe environment.

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Correct Answer is A

Explanation

A) Dehydration:
Diarrhea, especially when prolonged for several days, leads to significant fluid and electrolyte loss, which can result in dehydration. Common signs of dehydration include dry mucous membranes, decreased skin turgor, low urine output, hypotension, and increased heart rate. Dehydration is one of the most expected findings in a patient with prolonged diarrhea due to the loss of water and electrolytes from the body.
B) Rigid abdomen:
A rigid abdomen could indicate peritonitis or a serious abdominal condition such as bowel perforation, which is a medical emergency. This would not be expected in a patient with uncomplicated diarrhea. Rigid abdominal muscles are typically associated with acute abdominal emergencies rather than simple diarrhea.
C) Hypothermia:
Hypothermia is generally not associated with diarrhea. Diarrhea is more likely to cause fever or a normal body temperature due to the body's inflammatory response to infection or irritation. Hypothermia typically occurs in cases of prolonged exposure to cold or in critically ill patients, but it is not a typical response to diarrhea alone.
D) Decreased bowel sounds:
While decreased or absent bowel sounds can be seen in bowel obstruction or paralytic ileus, it is not typically a finding associated with diarrhea. In fact, in the early stages of diarrhea, increased bowel sounds (hyperactive bowel sounds) are often noted due to the rapid peristalsis and gastrointestinal irritation.

A. The client is underweight. B. The client takes anticoagulant medications. C. The client has urinary incontinence D. The client has peripheral vascular disease

Correct Answer is B

Explanation

A) The client is underweight:
Being underweight is not directly associated with an increased risk of incisional hematoma formation. However, underweight individuals may have a lower amount of subcutaneous fat, which could affect wound healing. While nutritional status plays a role in recovery after surgery, being underweight does not specifically increase the risk of hematoma formation at
the incision site.

B) The client takes anticoagulant medications:
Taking anticoagulant medications (e.g., warfarin, heparin, or newer anticoagulants like dabigatran) increases the risk of bleeding and the formation of an incisional hematoma. Anticoagulants work by reducing the blood's ability to clot, making it more difficult to stop bleeding after surgery. This increases the likelihood of blood accumulating in the tissue around the incision site, potentially forming a hematoma.

C) The client has urinary incontinence:
Urinary incontinence does not directly increase the risk of incisional hematoma formation. However, it can lead to other complications, such as skin irritation or infection, but it is not a primary risk factor for hematoma formation in the surgical wound. The main concern with urinary incontinence in the perioperative period is ensuring proper skin care to prevent moisture-associated skin damage.

D) The client has peripheral vascular disease:
Peripheral vascular disease (PVD) affects circulation in the extremities, which can impair wound healing due to decreased blood flow. While PVD can contribute to delayed healing and complications like infection, it is not the most significant factor for the formation of incisional hematomas.

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A nurse is teaching a newly licensed nurse about preventing puncture injuries, Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is B

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