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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Secure the restraints to the lowest bar of the side rail:
This is incorrect. Restraints should not be secured to the side rails of the bed because the client may injure themselves by attempting to climb over the side rail or if the bed adjusts, it can cause excessive pressure on the restrained limb.
B. Ensure four fingers under the restraints to prevent constriction:
This is incorrect. The nurse should be able to slide two fingers under the restraint to ensure it is not too tight, rather than four fingers. Restraining too loosely may allow the client to slip out, while restraining too tightly can cause tissue damage or compromise circulation.
C. Secure the restraints using a quick-release tie:
This is the correct action. Restraints should always have quick-release ties to allow for quick removal in case of an emergency or if the client needs to be repositioned or assisted. Velcro or buckle restraints with quick-release mechanisms are commonly used to ensure easy removal.
D. Anticipate removing the restraints every 4 hr:
While it's essential to regularly assess the need for continued restraint use and ensure restraints are not overly restrictive, there's no set time interval for removing restraints. Restraints should be removed as soon as they are no longer necessary to ensure the client's safety and comfort.

A. BP B. Weight C. Heart rate D. Urine output

Correct Answer is C

Explanation

A. BP (Blood Pressure): While monitoring blood pressure is important in assessing fluid status, a decrease in blood pressure may indicate inadequate fluid resuscitation rather than adequate replacement. Hypotension may suggest ongoing hypovolemia and the need for further fluid administration.
B. Weight: Weight may provide information about fluid balance over time, but it is not an immediate indicator of adequate fluid replacement during resuscitation. Changes in weight may lag behind changes in fluid status and may not reflect real-time fluid needs.
C. Heart rate: During fluid resuscitation for severe burn injuries, one of the primary goals is to restore intravascular volume and cardiac output. As fluid replacement improves, the heart rate typically decreases, reflecting improved perfusion and reduced sympathetic response.
D. Urine output: Urine output is another critical parameter to monitor during fluid resuscitation, but a decrease in urine output could indicate inadequate fluid replacement rather than adequate replacement.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Correct Answer is C

Explanation

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

A nurse is conducting a primary survey of a client who has sustained life threatening injuries due to a motor vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

A nurse is caring for four clients for whom she has to administer oral medications in the morning. The nurse should administer which of the following medications before breakfast?