A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Wash the puncture site with soap and water.

Squeeze as much blood as possible from the puncture site.

Flush the puncture site with water for 5 minutes.

Begin postexposure prophylaxis the following day.

Answer and Explanation

The Correct Answer is A

Choice A reason: The first step after a needlestick injury is to wash the wound with soap and water to reduce the risk of infection. This helps to remove any pathogens that may have been introduced into the puncture site.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: Postexposure prophylaxis (PEP) should be started as soon as possible, ideally within hours and no later than 72 hours after potential exposure to HIV. Waiting until the following day could decrease the effectiveness of PEP.

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Correct Answer is B

Explanation

Choice A reason: Droplet precautions are used for diseases that are spread by large respiratory droplets produced by coughing, sneezing, or talking. Examples include influenza, pertussis, and mumps. However, tuberculosis is not spread through large droplets but through airborne particles that can remain suspended in the air for long periods.

Choice B reason: Airborne precautions are necessary for diseases that are transmitted by smaller droplets, which can be suspended in the air for extended periods and can be inhaled. Tuberculosis, particularly pulmonary or laryngeal tuberculosis with a productive cough, requires airborne precautions because the bacteria can be expelled into the air and inhaled by others. The nurse should initiate airborne precautions, which include placing the patient in a negative pressure room and using personal protective equipment such as N95 respirators.

Choice C reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Examples include infections caused by multidrug-resistant organisms, scabies, and norovirus. Tuberculosis is not spread by direct contact, so contact precautions are not the primary method of prevention.

Choice D reason: Protective isolation, also known as neutropenic or reverse isolation, is used to protect immunocompromised patients from infections. It is not used for patients with tuberculosis, as the goal is to protect others from the tuberculosis bacteria, not to protect the patient from external infections.

A. Pulse 82/min, client sitting in a chair B. Temperature 36.9°C (98.4°F) C. Respirations auscultated, even at 22/min, client supine D. Blood pressure 108/68 mm Hg

Correct Answer is A

Explanation

Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.

Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.

Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.

Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.

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A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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