HESI Registered Nurse EXIT Practice Exam

What is the first action the nurse should take for a child who stepped on a rusty nail?

1. Cleanse the foot with soap and water and apply an antibiotic ointment

2. Provide teaching about the need for a tetanus booster within the next 72 hours

3. Have the mother check the child's temperature q4h for the next 24 hours

4. Transfer the child to the emergency department to receive a gamma globulin injection

The correct answer is: Cleanse the foot with soap and water and apply an antibiotic ointment

When a child steps on a rusty nail, the most immediate action that addresses potential infection is to cleanse the wound thoroughly with soap and water. This step is crucial as it helps to remove dirt, debris, and bacteria from the injury site, significantly reducing the risk of infection. Following cleansing, applying an antibiotic ointment aids in further protecting the wound from harmful bacteria while promoting healing. While educating about the need for a tetanus booster is important, it should occur after the initial cleaning of the wound. Similarly, monitoring temperature may be necessary if infection is suspected, but it does not address the immediate need for wound care. Transferring the child to the emergency department for a gamma globulin injection would not be the first step either; proper wound cleaning is needed beforehand. Thus, the most appropriate initial response to this scenario, taking into consideration immediate care and infection prevention, is to cleanse the foot and apply antibiotic ointment.