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

Report the incident to the charge nurse.

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

Go to employee health services.

Complete an incident report.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting the incident to the charge nurse is important, but it's not the first action to take in this situation. The immediate concern should be addressing the potential exposure to bloodborne pathogens.

Choice B rationale:

This is the correct choice. Washing the area of the puncture thoroughly with soap and water is the first step the nurse should take after an accidental needlestick. It helps reduce the risk of infection by cleaning the wound and removing any potential contaminants.

Choice C rationale:

Going to employee health services is a valid step, but it's not the immediate action needed after an accidental needlestick. Cleaning the wound should come first.

Choice D rationale:

Completing an incident report is important for documentation purposes, but it is not the nurse's first priority in this situation. Immediate wound care takes precedence.

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Correct Answer is C

Explanation

Choice A rationale:

Decreased tactile fremitus refers to a decreased vibration felt upon palpation of the chest, which might be indicative of conditions such as pleural effusion or pneumothorax. It is not directly associated with a crackling sensation.

Choice B rationale:

Pleural friction fremitus occurs when inflamed pleural surfaces rub against each other during breathing. It typically results in a grating sensation rather than a crackling sensation. It is associated with conditions like pleuritis.

Choice C rationale:

(Correct Choice) Crepitus refers to a crackling or grating sound/sensation that occurs when gas or air accumulates in the subcutaneous tissue. It can indicate a serious condition, such as subcutaneous emphysema, which might result from lung or chest wall injury, infections, or surgery.

Choice D rationale:

Rhonchal fremitus is associated with coarse breath sounds caused by thick secretions in the larger airways. It is felt as vibration during palpation and is not related to crackling sensations.

A. Clean the wound by scrubbing the site with gauze. B. Massage reddened areas with dressing changes. C. Reposition the client at least every 2 hours. D. Apply a heat lamp twice a day.

Correct Answer is C

Explanation

Choice A rationale:

Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.

Choice B rationale:

Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.

Choice C rationale:

(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.

Choice D rationale:

Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is examining the chest of a post-operative client. Upon palpation, the nurse notes a crackling sensation. Which of the following conditions would the nurse report to the provider?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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