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 D

Explanation

A. "I’m glad my child will have normal bowel movements now.": This statement indicates a misunderstanding of Hirschsprung disease. Surgery for Hirschsprung disease involves removing the portion of the large intestine affected by the condition, which often results in a temporary or permanent colostomy. While surgery aims to improve bowel function, it may not immediately result in normal bowel movements, especially if complications arise or additional surgeries are needed.
B. "I want to learn how to use my child's feeding tube as soon as possible.": This statement suggests a focus on enteral nutrition rather than the surgical management of Hirschsprung disease. While enteral feeding may be necessary for some children with Hirschsprung disease, the primary focus of initial surgery is to remove the affected portion of the large intestine and create an ostomy if needed, rather than addressing feeding tube use.
C. "I want to learn how to empty my child's urinary catheter bag.": This statement pertains to urinary catheter care rather than the surgical management of Hirschsprung disease. While urinary catheters may be used during surgery and recovery, they are not directly related to the treatment of Hirschsprung disease itself.
D. "I'm glad that my child's ostomy is only temporary": This statement demonstrates an understanding of the surgical management of Hirschsprung disease. Many children with Hirschsprung disease require surgery to remove the affected portion of the large intestine and create an ostomy, which may be temporary or permanent depending on the extent of the disease and the child's response to treatment. Recognizing that the ostomy is temporary indicates an understanding of the potential outcomes of surgery and the possibility of eventual bowel anastomosis.

A. Begin active range of motion. B. Remain on bedrest for the first 24 hr. C. Apply ice to the affected area D. Keep the leg in a dependent position.

Correct Answer is C

Explanation

A. Beginning active range of motion immediately after arthroscopic knee surgery may increase the risk of injury or disruption to the surgical site. Typically, passive range of motion exercises are initiated first under the guidance of a physical therapist or healthcare provider.
B. Remaining on bedrest for the first 24 hours after arthroscopic knee surgery is not typically recommended. Early mobilization and ambulation are encouraged to prevent complications such as blood clots and joint stiffness.
C. Applying ice to the affected area is a common postoperative instruction following knee surgery. Ice helps reduce swelling, inflammation, and pain. It is usually recommended for short intervals, such as 20 minutes every few hours, for the first 48 to 72 hours after surgery.
D. Keeping the leg in a dependent position (hanging down) for an extended period after knee surgery can increase swelling and discomfort. Elevating the leg when resting can help reduce swelling and improve circulation.

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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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Correct Answer is D

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Correct Answer is C

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