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

Answer and Explanation

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.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Rotavirus (RV): Rotavirus vaccine is routinely recommended for infants to protect against rotavirus infection, which can cause severe diarrhea and dehydration in young children. It is typically administered orally in multiple doses starting at around 2 months of age.
B. Human papillomavirus (HPV): The HPV vaccine is not routinely administered to infants at 1 year of age. It is typically recommended for preteens and adolescents to protect against HPV-related cancers and genital warts.
C. Measles, mumps rubella (MMR): The MMR vaccine is routinely given to infants around 1 year of age to protect against measles, mumps, and rubella (German measles). It is typically administered as a single injection.
D. Varicella (VAR): The varicella vaccine is routinely recommended for infants to protect against chickenpox (varicella) infection. It is typically administered as a single injection around 1 year of age.
E. Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is routinely given to infants to protect against diphtheria, tetanus, and pertussis (whooping cough). It is typically administered as a series of injections starting at around 2 months of age.

A. Lubricate the suction catheter tip with sterile saline B. Suction two to three times with a 50-second pause between passes C. Hyperventilate the client on 100% oxygen prior to suctioning D. Perform chest physiotherapy prior to suctioning E. None F. None

Correct Answer is C

Explanation

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

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While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse cake first?

Nursing Test Bank

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