after a needle stick occurs while removing the cap from a sterile needle which action should the nurse implement
Logo

Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. After a needle stick occurs while removing the cap from a sterile needle, what action should the individual take?

Correct answer: B

Rationale: In the scenario described, the correct action after a needle stick injury is to discard the contaminated needle safely and choose a new sterile needle to continue the procedure. This step helps prevent potential transmission of infections and ensures the safety of both the individual and the patient. Disinfecting the needle with an alcohol swab is not adequate to address the risk of infection transmission. While completing an incident report and notifying the supervisor are important, the immediate action should be to replace the contaminated needle with a new sterile one to prevent any potential harm.

2. Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client’s plan of care?

Correct answer: B

Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

3. The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?

Correct answer: B

Rationale: The correct answer is B: Right cephalic vein. The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care. Choices A, C, and D are incorrect because the left brachial vein, the dorsal side of the right wrist, and the right upper extremity are not typically preferred sites for IV catheter insertion and may not provide optimal access or outcomes.

4. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

Correct answer: C

Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.

5. The healthcare professional counts an adult's apical heartbeat at 110 beats per minute. The healthcare professional describes this as:

Correct answer: C

Rationale: Tachycardia is a heart rate greater than 100 beats per minute. In this case, an adult's heart rate of 110 beats per minute falls within the range of tachycardia. Tachycardia can be a common physiological response to various stresses on the body, leading to an increased heart rate. Asystole refers to the absence of cardiac activity, bigeminy is a specific heart rhythm pattern, and bradycardia is a heart rate below 60 beats per minute in adults.

Similar Questions

A seriously ill female client tells the nurse, 'I am so tired and in so much pain! Please help me to die.' Which is the best response for the nurse to provide?
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?
When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses