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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.
Choice B rationale:
Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.
Choice C rationale:
Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.
Choice D rationale:
Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.
Correct Answer is B
Explanation
Choice B rationale:
The nurse should avoid assessing the popliteal pulse bilaterally at the same time. The popliteal pulse is located behind the knee and is relatively deep. Applying pressure on both sides of the knee to assess this pulse simultaneously can obstruct blood flow to the lower extremities. This is a particularly important consideration for clients with compromised circulation, such as those with peripheral vascular disease. Assessing this pulse sequentially is a safer approach.
Choice A rationale:
Assessing the femoral pulse bilaterally at the same time is generally acceptable. The femoral pulse is located in the groin area, and assessing it bilaterally doesn't impede blood flow significantly.
Choice C rationale:
Assessing the brachial pulse bilaterally at the same time is generally acceptable. The brachial pulse is located in the upper arm, and simultaneous assessment is unlikely to cause circulatory compromise.
Choice D rationale:
Assessing the carotid pulse bilaterally at the same time is discouraged. The carotid arteries are located in the neck, and applying bilateral pressure here can lead to reduced blood flow to the brain, potentially causing syncope (fainting) or other adverse effects. It's safer to assess this pulse sequentially.
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