The practical nurse (PN) administers an injection using a syringe with a retractable needle. After the needle is removed from the client's skin, the needle does not retract, and the PN gets stuck in the finger with the used needle. What action should the PN take first?

Choice A rationale:

After administering hydrocodone/acetaminophen for pain, the PN should closely monitor the client for signs of respiratory depression, which may manifest as shallow or slow breathing.

Ongoing assessments are crucial because respiratory depression is a potential adverse effect of opioid medications like hydrocodone. If this complication is detected early, appropriate interventions can be implemented to ensure the client's safety.

Choice B rationale:

Assessing the skin daily for areas of ecchymosis or other signs of bleeding is not directly related to the administration of hydrocodone/acetaminophen. While bruising and bleeding are possible side effects of some medications, this assessment is not the priority in this scenario.

Choice C rationale:

Encouraging the client to resume normal activities after medication administration is not appropriate in this situation. Hydrocodone/acetaminophen can cause drowsiness and impairment, so the client should be advised to avoid activities that require alertness or coordination until the effects of the medication are known.

Choice D rationale:

Observing the client for involuntary movements of the lips and tongue is relevant when administering antipsychotic medications, as these movements may be signs of tardive dyskinesia. However, it is not directly related to the use of hydrocodone/acetaminophen. The priority after administering this pain medication is to monitor for respiratory depression, as opioids can affect the respiratory system

The correct answer is Choice B. Report the finding to the charge nurse. Choice A rationale:

Checking for kinks in the drainage tubing is an important troubleshooting step if there is a sudden decrease or absence of urine output. However, in this case, the PN's concern is the presence of thick red fluid with clots in the urine drainage. This finding indicates potential bleeding, which requires immediate attention and reporting.

Choice B rationale:

Reporting the finding to the charge nurse is the correct action. The presence of thick red fluid with clots in the urine suggests significant bleeding after the transurethral resection of the prostate (TURP) surgery. It is crucial to inform the charge nurse or the healthcare provider promptly so that appropriate interventions can be initiated to address the bleeding.

Choice C rationale:

Stopping the irrigation solution immediately may not be within the PN's scope of practice unless explicitly instructed by the healthcare provider. Moreover, abruptly stopping the irrigation may lead to complications, and it is essential to involve the charge nurse or healthcare provider in making this decision.

Choice D rationale:

Observing the drainage again in one hour is not appropriate in this situation. The presence of thick red fluid with clots in the urine drainage is an urgent concern that requires immediate action, not a wait-and-see approach.