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. Dehydration is a common finding in clients who have experienced diarrhea for several days, as they may have lost significant fluid and electrolytes.
B. A rigid abdomen is more characteristic of conditions such as perforation or severe peritonitis rather than diarrhea.
C. Decreased bowel sounds may occur in certain conditions, but diarrhea typically presents with increased bowel sounds due to hyperactivity.
D. Hypothermia is not a common finding associated with diarrhea; instead, clients may have a normal or elevated temperature due to potential underlying infections.
Correct Answer is C
Explanation
A. Obtaining the client's consent is the responsibility of the provider, not the nurse. The nurse should ensure the client is informed but cannot independently obtain consent.
B. It is not within the nurse's scope of practice to explain the procedure in detail; this is the responsibility of the healthcare provider. The nurse can clarify information if the client has questions but should not assume the role of the educator regarding the procedure.
C. Witnessing the client's signature is an appropriate action for the nurse once the client has received information from the provider and understands the procedure, as it confirms that the client voluntarily consents.
D. Explaining the risks and benefits of the procedure is also the responsibility of the healthcare provider, as they are the ones performing the procedure and are qualified to discuss it in detail.