While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse cake first?

A. Apply petroleum jelly to the client's lips after oral care: Applying petroleum jelly to the client's lips can help prevent dryness and cracking, particularly in immobile clients who may have difficulty maintaining moisture in their oral mucosa. This action helps promote comfort and prevent complications such as lip fissures and discomfort during oral care. Therefore, it is an appropriate action for the nurse to take.
B. Use the thumb and index finger to keep the client's mouth open: Forcing the client's mouth open with the thumb and index finger can be uncomfortable and may cause injury. Gentle techniques should be employed to maintain the client's mouth open if necessary, such as using a mouth prop or asking the client to open their mouth voluntarily.
C. Turn the client on his side before starting oral care: Turning the client on their side is an essential safety measure, particularly for immobile clients, to prevent aspiration and facilitate drainage of oral secretions during oral care. This position helps ensure that any excess fluid or debris can drain out of the mouth rather than pooling in the back of the throat, reducing the risk of aspiration pneumonia. Therefore, it is an appropriate action for the nurse to take.
D. Use a stiff toothbrush to clean the client's teeth: Using a stiff toothbrush can cause injury to the client's gums and oral tissues, especially if the client is immobile or has delicate oral tissues due to medical conditions or treatments. A soft-bristled toothbrush or sponge applicator should be used for oral care to avoid trauma and ensure thorough but gentle cleaning.

A. Open the airway using a jaw-thrust maneuver: The first step in a primary survey is to assess the airway and ensure it is open. The jaw-thrust maneuver is used to open the airway without moving the neck in case of a potential cervical spine injury.

C. Determine effectiveness of ventilator efforts: Once the airway is open, the next step is to assess breathing. This includes observing for chest rise and fall, listening for breath sounds, and feeling for air movement.

B. Establish IV access: After the airway and breathing have been assessed, circulation is the next priority. This includes establishing IV access for fluid and medication administration.

D. Perform a Glasgow Coma Scale assessment: The Glasgow Coma Scale is used to assess the client’s level of consciousness, which is part of the disability assessment in the primary survey.

E. Remove clothing for a thorough assessment: Finally, removing the client’s clothing allows for a thorough assessment of injuries. This is typically done after the immediate life-threatening issues have been addressed.