A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library.
Which intervention is most crucial for the nurse to implement?

Pay close attention to the client’s account of the event.

Report the incident to the university’s security department.

Prevent the client from showering until all evidence is collected.

Ascertain the client’s personal reaction to the reported rape.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Paying close attention to the client’s account of the event is important, but it is not the most crucial intervention. The nurse should listen empathetically and nonjudgmentally to the client’s account, but this should not take precedence over ensuring the client’s physical well- being and preserving evidence.
Choice B rationale

Reporting the incident to the university’s security department is not the most crucial intervention. While it is important to report the incident to the appropriate authorities, the nurse’s primary responsibility is to the client. Ensuring the client’s physical well-being and preserving evidence should take precedence.
Choice C rationale
Preventing the client from showering until all evidence is collected is the most crucial intervention. Showering can destroy valuable physical evidence that can be used in the investigation and prosecution of the crime.
Choice D rationale
Ascertaining the client’s personal reaction to the reported rape is important, but it is not the most crucial intervention. The nurse should provide emotional support and refer the client to counseling services, but this should not take precedence over ensuring the client’s physical well-being and preserving evidence.

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Correct Answer is C

Explanation

Choice A rationale

While seizure precautions are important for clients receiving certain medications or with certain conditions, they are not typically necessary for clients receiving dopamine. Dopamine, an adrenergic agonist, does not typically increase the risk of seizures.

Choice B rationale

Assessing pupillary response to light hourly is not typically necessary for clients receiving dopamine. Dopamine does not typically affect pupillary response.

Choice C rationale

Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine at low to moderate doses can dilate renal blood vessels, which can increase urine output. Therefore, monitoring urinary output can help assess the effectiveness of the medication and the client’s renal perfusion.

Choice D rationale

While it is important to monitor electrolyte levels in clients receiving certain medications, frequent monitoring of serum potassium is not typically necessary for clients receiving dopamine. Dopamine does not typically affect serum potassium levels.

A. Cease the use of the nasal cannula. B. Reduce the flow rate to 1 L/minute. C. Apply lubricant to the cannula tubing. D. Attach padding around the cannula tubing.

Correct Answer is D

Explanation

Choice A rationale
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.

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A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most crucial for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is C

Explanation

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

Correct Answer is D

Explanation

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A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library.
Which intervention is most crucial for the nurse to implement?