While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse cake first?
Complete an incident report.
Consent to postexposure treatment with antiretroviral medications
Request the risk manager obtain consent for HIV testing from the client.
Wash the site of injury with soap and water
The Correct Answer is D
A. Complete an incident report: While completing an incident report is important for documentation purposes, it should not be the first action taken after a needle stick injury. Immediate attention to the wound by washing it with soap and water takes precedence to minimize the risk of infection.
B. Consent to postexposure treatment with antiretroviral medications: Postexposure prophylaxis (PEP) with antiretroviral medications may be indicated after a needle stick injury, particularly if there is a risk of exposure to HIV or other bloodborne pathogens. However, obtaining consent for PEP should follow immediate wound care.
C. Request the risk manager obtain consent for HIV testing from the client: While HIV testing may be necessary for the client involved in the incident, it is not the nurse's responsibility to obtain consent for testing. The priority is to address the nurse's own immediate health and safety by cleaning the wound and seeking appropriate medical evaluation and treatment.
D. Wash the site of injury with soap and water: The first action the nurse should take after experiencing a needle stick injury is to immediately wash the site of the injury with soap and water. This helps reduce the risk of infection by removing any potentially infectious material from the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypocalcemia: Hypocalcemia, or low levels of calcium in the blood, is not typically associated with an increased risk of urolithiasis. In fact, hypercalcemia, or high levels of calcium, is more commonly linked to the formation of calcium-based kidney stones.
B. Diuretic use: Diuretic medications can increase urine production and may contribute to dehydration, which can predispose individuals to the formation of kidney stones. However, diuretic use alone is not as significant a risk factor as other factors like dehydration or specific dietary habits.
C. Family history: Family history of urolithiasis is a significant risk factor for developing kidney stones. Genetic factors can influence the likelihood of stone formation, and individuals with a family history of kidney stones are at a higher risk of experiencing them themselves.
D. BMI less than 25: Obesity and higher BMI (body mass index) are associated with an increased risk of urolithiasis. Excess body weight can lead to metabolic changes that promote the formation of kidney stones. Therefore, having a BMI less than 25 is less likely to be a risk factor compared to having a higher BMI.
Correct Answer is C
Explanation
A. Bleeding: While haloperidol can rarely cause agranulocytosis, which may lead to bleeding, it is not a common adverse effect associated with the medication. However, clients taking antipsychotic medications like haloperidol should be monitored for any signs of bleeding, such as petechiae or bruising.
B. Cataracts: Haloperidol is not typically associated with the development of cataracts. However, long-term use of certain antipsychotic medications, including haloperidol, may increase the risk of developing metabolic side effects such as weight gain and dyslipidemia, which could indirectly contribute to the risk of cataract formation.
C. Dysrhythmias: This is the correct answer. Haloperidol has the potential to prolong the QT interval, leading to a type of dysrhythmia known as torsade’s de pointes. Therefore, clients taking haloperidol should be monitored for signs of QT prolongation, such as palpitations, syncope, or sudden cardiac arrest.
D. Pancreatitis: While rare, haloperidol has been associated with pancreatitis as a potential adverse effect. However, dysrhythmias are a more common and immediate concern, especially with acute administration or in clients with predisposing factors for QT prolongation, such as electrolyte imbalances or concurrent use of other medications known to prolong the QT interval.
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