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 D
Explanation
A. Requesting an order for an antiemetic may be necessary if the client continues to experience nausea, but it is not the first action the nurse should take. Before administering medication, the nurse should assess the client's vital signs and overall condition to determine the appropriate intervention.
B. While a dietitian consult may be beneficial to address the client's nutritional needs, it is not the first action the nurse should take in response to the client's symptoms of nausea and weakness. Assessing the client's vital signs and condition should be the priority.
C. Suggesting that the client rests before eating the meal may be helpful, but it does not address the underlying cause of the client's symptoms. The nurse should first assess the client's vital signs to determine the severity of the symptoms and any potential complications.
D. Checking the client's vital signs is the first action the nurse should take in response to the client's symptoms of nausea and weakness. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, can provide valuable information about the client's hemodynamic status and help identify any potential complications, such as dehydration or worsening heart failure. Based on the vital signs assessment, the nurse can then implement appropriate interventions, such as notifying the healthcare provider or providing symptomatic relief.
Correct Answer is D
Explanation
A. Instruct the client to stay in the same position for 2 min: While it is important for the client to remain in a supine position with the head tilted back slightly after instilling nasal decongestant drops, there is no need for the client to remain in the same position for a specific duration such as 2 minutes.
B. Tell the client to blow her nose gently before the instillation: Blowing the nose before instilling nasal decongestant drops is not necessary and may cause irritation to the nasal passages. The drops should be instilled directly into the nasal passages without prior blowing of the nose.
C. Assist the client to a side-lying position: There is no need to assist the client to a side-lying position for the administration of nasal decongestant drops. The drops are typically administered with the client in a seated or supine position with the head tilted back slightly.
D. Hold the dropper 2 cm (1 in) above the nares: This is the correct action. Holding the dropper approximately 2 cm (1 in) above the nares allows for precise instillation of the drops into the nasal passages without touching the dropper to the nares, which helps prevent contamination.
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