A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?
Wash the area of the puncture thoroughly with soap and water.
Go to employee health services.
Complete an incident report.
Report the incident to the charge nurse.
The Correct Answer is A
A. Washing the area of the puncture thoroughly with soap and water is the first and most immediate action to reduce the risk of infection and transmission of bloodborne pathogens. This should be done as soon as possible after the injury.
B. Going to employee health services is necessary but should follow immediate first aid measures.
C. Completing an incident report is important for documentation and accountability but is not the immediate priority after a needle-stick injury.
D. Reporting the incident to the charge nurse is necessary for proper protocol but does not take precedence over ensuring the injury is properly cleaned first.
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Correct Answer is D
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.
Correct Answer is C
Explanation
A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.
B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.
C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.
D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.