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 ["1.80"]

Explanation

Step 1 is to convert the patient’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.20462 pounds. So, the patient’s weight in kilograms is 132 pounds ÷ 2.20462 = 59.87 kg.

Step 2 is to calculate the total dosage of dantrolene needed. The prescribed dosage is 1.5 mg/kg. So, the total dosage is 1.5 mg/kg × 59.87 kg = 89.81 mg.

Step 3 is to calculate the volume of reconstituted dantrolene solution needed to provide the total dosage. The reconstituted solution has a concentration of 50 mg/mL. So, the volume needed is 89.81 mg ÷ 50 mg/mL = 1.80 mL.

A. Reiterate the need for the UAP to wear a face mask while in close contact with the client. B. Reassign the UAP to provide care for another client and assume full care of the client. C. Direct the UAP to alert the nurse of any changes in the client’s respiratory status. D. Remind the UAP to wear a fitted respirator mask before entering the client’s room.

Correct Answer is A

Explanation

Choice A rationale

The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.

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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 patient with neuroleptic malignant syndrome has been prescribed dantrolene 1.5 mg/kg IV. The patient weighs 132 pounds. The label on the 250 mg vial reads, “Reconstitute with 5 mL sterile water for injection, USP. Reconstitution yields 50 mg/mL.”. How many mL should the nurse administer?

Correct Answer is ["1.80"]

Explanation

A client with influenza requires assistance in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

Correct Answer is A

Explanation

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

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?

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

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?

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?