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 A
Explanation
A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.
B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.
C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.
D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.
Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.