A nurse accidentally sticks her hand with a syringe after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroughly with soap and water.

Notify the employee health services

Complete an incident report

Report the incident to the charge nurse

Answer and Explanation

The Correct Answer is A

A. Wash the area of the puncture thoroughly with soap and water: The first action the nurse should take after a needlestick injury is to immediately wash the area with soap and water. This is crucial for minimizing the risk of infection and exposure to potentially infectious materials. Prompt cleaning of the puncture site is essential in reducing the risk of transmission of bloodborne pathogens.

B. Notify employee health services: While notifying employee health services is important for follow-up care and evaluation, it should be done after the initial wound care has been performed. Immediate action should focus on cleaning the injury first.

C. Complete an incident report: Completing an incident report is a necessary step for documentation and accountability in the healthcare setting. However, it should be done after the immediate first aid for the needlestick injury has been addressed.

D. Report the incident to the charge nurse: Reporting the incident to the charge nurse is important for ensuring appropriate follow-up and support, but the priority should be to address the injury first. The nurse should take care of the puncture wound before notifying others about the incident.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Obtain the provider's prescription renewal every 72 hr.: This is an essential intervention. Restraints must be prescribed by a provider and typically require renewal every 24 to 72 hours, depending on hospital policy and the client's needs. Continuous monitoring and justification for the use of restraints are necessary for ethical and legal compliance.

B. Document restraint checks and client status every 2 hr.: Regular documentation of restraint checks and the client’s status is vital for ensuring safety and monitoring for any potential complications, such as skin breakdown or circulatory issues. Frequent checks help ensure that restraints are being used appropriately and that the client’s needs are being met.

C. Implement passive range-of-motion exercises: Incorporating passive range-of-motion exercises is important for preventing joint stiffness, muscle atrophy, and promoting circulation in an immobile client. These exercises can help maintain some level of mobility and prevent complications associated with prolonged immobility.

D. Educate the client's family about restraint use: Providing education to the family about the rationale for using restraints, their purpose, and the monitoring process is essential for transparency and support. This helps the family understand the situation and the measures being taken to ensure the client’s safety.

E. Release the restraint and reposition the client every 4 hr.: This intervention is not sufficient, as restraints should typically be released more frequently, generally every 1 to 2 hours, to assess the client's condition, provide comfort, and allow for repositioning. Releasing restraints every 4 hours may increase the risk of complications and does not align with best practices for care.

A. A 60 year old patient who is on a mechanical ventilator B. A 65 year old patient who is vegetarian and obese C. A 45 year old patient who smokes a pack of cigarettes a day D. A 70 year old patient who has a normal WBC count

Correct Answer is A

Explanation

A. A 60 year old patient who is on a mechanical ventilator: This patient is at the highest risk for healthcare-acquired infections (HAIs) due to the use of mechanical ventilation. Ventilated patients are susceptible to ventilator-associated pneumonia and other respiratory infections, making them more vulnerable to HAIs.

B. A 65 year old patient who is vegetarian and obese: While obesity can increase the risk for certain complications, being vegetarian does not inherently increase the risk for HAIs. This patient may have some risk factors, but they are not as significant as those associated with mechanical ventilation.

C. A 45 year old patient who smokes a pack of cigarettes a day: Smoking is a risk factor for various health issues, including respiratory infections, but it does not specifically correlate with a higher risk of HAIs in a hospitalized setting compared to a patient on a mechanical ventilator.

D. A 70 year old patient who has a normal WBC count: Although older age can increase the risk for infections, a normal white blood cell count indicates a functioning immune response. Without additional risk factors, this patient would not be considered the most at risk for developing HAIs compared to a ventilated patient.

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A nurse accidentally sticks her hand with a syringe after administering an IM injection to a client. Which of the following actions should the nurse take first?

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