# A nurse sustains a deep percutaneous injury from a hollow-bore needle that was just used on a hospitalized client with HIV whose most recent viral load is documented as undetectable. The nurse safely removes the needle and disposes of it, then must decide which actions are appropriate to reduce the risk of occupational HIV transmission. Which actions should the nurse take next? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=558429&lang=en > language: en > subject: Standard/Transmission-Based Precautions/Surgical Asepsis > category: SIPC ## Question A nurse sustains a deep percutaneous injury from a hollow-bore needle that was just used on a hospitalized client with HIV whose most recent viral load is documented as undetectable. The nurse safely removes the needle and disposes of it, then must decide which actions are appropriate to reduce the risk of occupational HIV transmission. Which actions should the nurse take next? Select all that apply. 1 Wash the puncture wound immediately with soap and water after safely disposing of the needle. 2 Squeeze the puncture wound repeatedly to force out blood before washing it with soap and water. 3 Notify the occupational health department immediately to begin a post-exposure risk assessment. 4 Withhold postexposure prophylaxis because the source client's most recent viral load is documented as undetectable. 5 Delay starting the prophylaxis regimen until the nurse's baseline HIV test results are finalized. 6 Obtain a baseline blood sample for HIV antibody testing as part of the initial exposure evaluation. ## Explanation Immediate wound care with soap and water is the first recommended action after a percutaneous exposure because it physically reduces contamination, while squeezing the site offers no proven benefit and may worsen tissue injury. Prompt notification of occupational health ensures rapid risk assessment and expert decision-making about prophylaxis, which should begin as soon as possible after exposure for maximum effectiveness. An undetectable source viral load reduces but does not remove transmission risk, so it should not be used alone to cancel prophylaxis. Baseline testing for the exposed nurse is collected during the initial evaluation for future comparison, but starting prophylaxis should never be postponed while awaiting those results, since delay diminishes the treatment's protective value. ## In-depth explanation Correct Answer Choices 1, 3, 6 Clinical Reasoning Immediate wound care with soap and water is the first recommended action after a percutaneous exposure because it physically reduces contamination, while squeezing the site offers no proven benefit and may worsen tissue injury. Prompt notification of occupational health ensures rapid risk assessment and expert decision-making about prophylaxis, which should begin as soon as possible after exposure for maximum effectiveness. An undetectable source viral load reduces but does not remove transmission risk, so it should not be used alone to cancel prophylaxis. Baseline testing for the exposed nurse is collected during the initial evaluation for future comparison, but starting prophylaxis should never be postponed while awaiting those results, since delay diminishes the treatment's protective value. Option Review - Correct — Washing the wound immediately with soap and water is the first recommended step after a percutaneous exposure to remove contaminated blood and reduce transmission risk. - Incorrect — Squeezing the puncture site repeatedly is not supported by current evidence and may cause additional tissue trauma without lowering exposure risk. - Correct — Notifying occupational health immediately allows a timely risk assessment and rapid access to expert guidance on starting postexposure prophylaxis. - Incorrect — An undetectable viral load in the source client lowers but does not eliminate transmission risk, so prophylaxis should not be withheld based on that value alone. - Incorrect — Waiting for the nurse's baseline test results delays initiation of prophylaxis, which is most effective when started as soon as possible after exposure. - Correct — Obtaining a baseline blood sample allows later comparison of results but should occur without postponing the start of postexposure prophylaxis. Sources 12026 NCLEX-RN Test Plan 2CDC: 2025 U.S. Public Health Service occupational HIV PEP guidelines ## Clinical scenario A nurse experiences a deep percutaneous needlestick from a hollow-bore needle just used on a hospitalized client with HIV whose most recent viral load is documented as undetectable, requiring the nurse to determine the correct immediate postexposure actions. ## Related questions - [A nurse is caring for a client newly admitted with suspected methicillin-resistant Staphyl…](https://mymerci.kr/pages/nclex_q.php?qn_id=360517&lang=en) - [A nurse is about to enter the room of a client with Clostridioides difficile infection dur…](https://mymerci.kr/pages/nclex_q.php?qn_id=361226&lang=en) - [A 22-year-old female client presents to the emergency department with a 4-week history of …](https://mymerci.kr/pages/nclex_q.php?qn_id=361677&lang=en) - [A 65-year-old client admitted to the medical ICU with sepsis and acute delirium has just p…](https://mymerci.kr/pages/nclex_q.php?qn_id=361679&lang=en) - [A new graduate registered nurse (RN) on a medical unit just hung an intravenous antibiotic…](https://mymerci.kr/pages/nclex_q.php?qn_id=361710&lang=en) - [A nurse is caring for a client newly admitted with active Clostridioides difficile infecti…](https://mymerci.kr/pages/nclex_q.php?qn_id=363996&lang=en) - [A nurse is caring for an adult client newly admitted with suspected active pulmonary tuber…](https://mymerci.kr/pages/nclex_q.php?qn_id=366306&lang=en) - [A nurse cares for a client newly admitted with a positive surveillance culture for vancomy…](https://mymerci.kr/pages/nclex_q.php?qn_id=366709&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=558429&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=558429&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=558429&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=558429&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=558429&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. 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