After administering an injection, the nurse observes bleeding at the site. In what sequence should the nurse perform these actions? (Arrange with the first step on top and the last step on the bottom.)
Retract the needle into the syringe.
Place syringe in a puncture-resistant container.
Apply an adhesive bandage over the injection site.
Remove disposable exam gloves.
The Correct Answer is A,B,D,C
Choice A: Retracting the needle into the syringe should be done before safely disposing of the syringe.
Choice B: Placing the syringe in a puncture-resistant container is the second step to ensure safe disposal of sharp objects.
Choice C: Applying an adhesive bandage over the injection site is the final step to address the bleeding and protect the site.
Choice D: Removing disposable exam gloves is the next step to prevent any contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: A thready pulse is one that is weak and can be easily obliterated by light pressure.
Choice B: A missing pulse is one that cannot be felt at all.
Choice C: "Pulse skips beats" is a different phenomenon and not an accurate description of the pulse disappearing with light pressure. It is irregular and may indicate a cardiac arrhythmia.
Choice D: Documenting "light pressure applied to pulse" does not convey the specific finding that the pulse disappears with pressure, which is more clinically relevant. It is not a finding, but a method of assessing the pulse.
Correct Answer is D
Explanation
Choice A rationale: Referring the client to a dietitian for nutrition education is a proactive step. Dietitians can provide personalized guidance and address the client's dietary concerns and preferences. However, this alone may not be sufficient if the client is strongly resistant to dietary changes.
Choice B rationale: Providing pamphlets about heart-healthy diet selections is informative but may not effectively address the client's resistance to dietary changes. The client's reluctance needs to be explored and addressed through a more interactive approach.
Choice C rationale: While exercise is important for heart health, the primary concern here is the client's elevated cholesterol levels, which are significantly impacted by dietary choices. Suggesting exercise alone may not adequately address the issue at hand.
Choice D rationale: Discussing the client's concerns about the change in diet is the most appropriate initial action. It allows the nurse to understand the client's perspective, identify barriers to compliance, and work collaboratively with the client to develop a plan that considers his preferences and challenges. This approach is more likely to lead to a successful change in diet and lifestyle compared to simply providing information or referrals.
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