A nurse is teaching a client who has left-sided weakness after a stroke on how to use a cane. What instructions should the nurse include?

Choice A Reason:

Washing the area of the puncture thoroughly with soap and water is the first and most immediate action the nurse should take. This step helps to reduce the risk of infection by removing any potential contaminants from the puncture site. It is a crucial initial response to any needlestick injury to minimize the risk of bloodborne pathogen transmission. Proper hand hygiene is essential in preventing infections and ensuring the safety of healthcare workers.

Choice B Reason:

Notifying employee health services is an important step that should follow the initial first aid. Employee health services will provide further evaluation, testing, and follow-up care as needed. They will also guide the nurse on any necessary post-exposure prophylaxis and additional steps to take. However, this is not the first action to take immediately after the injury.

Choice C Reason:

Completing an incident report is a necessary step to document the needlestick injury. This report helps in tracking and preventing future incidents, ensuring that proper protocols are followed, and providing data for workplace safety improvements. While important, this step should be taken after the initial first aid and notification of employee health services.

Choice D Reason:

Reporting the incident to the charge nurse is also an important step in the process. The charge nurse needs to be informed about the incident to ensure that appropriate follow-up actions are taken and to provide support to the affected nurse. However, this step should come after the immediate first aid and notification of employee health services.

Choice A Reason:

“Call the provider” is important but not the first priority. The immediate concern is to maintain the client’s intravenous access to ensure they can receive any necessary medications or fluids promptly. Once the line is secured, the provider should be notified to receive further instructions and manage the client’s condition.

Choice B Reason:

“Notify the blood bank” is also crucial but comes after ensuring the client’s immediate safety. The blood bank needs to be informed to investigate the cause of the reaction and prevent further issues, but this step follows the initial emergency interventions.

Choice C Reason:

“Collect a urine specimen” is necessary to check for hemolysis, which can occur during a transfusion reaction. However, this is not the first step. The priority is to stabilize the client by maintaining IV access with normal saline.

Choice D Reason:

“Keep the line open with 0.9% NS through new tubing” is the correct first intervention. This action ensures that the client remains hydrated and that the IV line is available for any emergency medications or treatments. Using new tubing prevents any contamination from the transfusion set.