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While starting a peripheral vascular access device (VAD) on a client, the nurse suffers a needlestick injury. Which action should the nurse take?
- A. Ask the client if they have the hepatitis A virus.
- B. Wash the affected extremity with soap and water.
- C. Document the incident in the client's medical record.
- D. Discontinue the vascular access device.
Correct Answer: B
Rationale: Washing with soap and water is the initial action to reduce infection risk after a needlestick.
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Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.
The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following?
- A. Wear gloves and a gown.
- B. Perform hand hygiene.
- C. Review the client's viral load.
- D. Obtain a disposable stethoscope.
Correct Answer: B
Rationale: Hand hygiene is required before entering any client’s room to prevent infection spread. Gloves/gown, viral load review, and disposable stethoscopes are not routinely needed for AIDS.
The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first?
- A. Obtain a fire extinguisher
- B. Close the bathroom door
- C. Remove the client from the room
- D. Activate the fire alarm
Correct Answer: C
Rationale: Removing the client from the room prioritizes safety in a potential fire hazard. Other actions follow after ensuring client safety.
The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern?
- A. Infection
- B. Thermoregulation
- C. Hemorrhage
- D. Altered body image
Correct Answer: C
Rationale: Hemorrhage is the greatest concern immediately post-colon resection due to the risk of significant blood loss from the surgical site, which can be life-threatening. Infection, thermoregulation, and altered body image are important but less immediate.