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A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

Ensure that the police are present when the examination is performed.

Assess and document any bruises and lacerations.

Have the patient shower or wash the perineal area before the examination.

Record a history of the event, using the patient's own words.

Answer and Explanation

Correct Answer : A,C,E

A. Labeling all torn or bloody clothes and placing each item in a separate brown bag is correct as it helps preserve forensic evidence.
B. Ensuring that the police are present during the examination is incorrect because the patient has the right to refuse police presence, and privacy should be maintained.
C. Assessing and documenting any bruises and lacerations is correct to provide an accurate record for legal and medical purposes.
D. Having the patient shower or wash the perineal area before the examination is incorrect because it can destroy crucial forensic evidence.
E. Recording a history of the event using the patient’s own words is correct as it ensures accurate documentation without interpretation or bias.

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Correct Answer is B

Explanation

A. The prone position is not recommended for managing tube feeding regurgitation, as it could lead to aspiration into the lungs.
B. The first priority is to ensure that the tracheostomy cuff is inflated during tube feedings to prevent aspiration and to ensure that the feeding is directed into the stomach and not into the airway.
C. The lateral decubitus position can help with gastric emptying, but the priority is to ensure proper cuff inflation to prevent aspiration.
D. While metoclopramide may help with gastric motility, the immediate concern is managing the risk of aspiration, which requires confirming cuff inflation.

A. Have the client deep breathe and hold B. Assist the client to ambulate on the nursing unit C. Encourage the client to watch television D. Apply ice to the incision site for 30 minutes

Correct Answer is A

Explanation

A. Deep breathing and holding can help relax the patient, reduce pain perception, and enhance the effects of opioid medications.
B. Ambulating may be appropriate but should be done carefully, as it could exacerbate pain or cause dizziness after opioid administration.
C. While distraction like watching TV can help manage pain, it is not as effective as active pain-relieving interventions like deep breathing.
D. Applying ice to the incision site can be helpful for pain management, but deep breathing is more directly beneficial for managing postoperative pain.

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A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A tracheostomy patient is experiencing regurgitation of tube feeding formula. What should be the nurse's first priority?

Correct Answer is B

Explanation

The client experienced abdominal surgery the previous day and has just received an opioid medication for report of pain. The client is sitting in a chair next to the bed. An additional activity that the nurse uses to relieve pain is:

Correct Answer is A

Explanation

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