The nurse who working in the emergency department is obtaining 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 important for the nurse to implement?

A Report the incident to the university's security department.

B Determine the client's personal reaction to the reported rape.

C Listen attentively to the client's description of the event.

D Do not allow client to shower until all evidence is obtained.

Answer and Explanation

The Correct Answer is D

A. Reporting the incident to the university's security department is an important step but not the immediate priority. The primary focus in the emergency department is to preserve forensic evidence for legal purposes.
B. While understanding the client's personal reaction is important for providing emotional support, it does not take precedence over the immediate need to preserve evidence.
C. Listening to the client’s description of the event is part of the process, but preserving evidence is more critical. The main goal during the examination is to collect and document physical evidence rather than focusing on the details of the event.
D. Ensuring the client does not shower is crucial as it preserves physical evidence from the assault, which is essential for the investigation and legal proceedings.

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Correct Answer is B

Explanation

A. Aching leg: This is not a common issue related to gastric endoscopy and is not typically addressed as a post-procedure concern.
B. Sore throat: This is a common post-procedure symptom due to the insertion of the endoscope through the mouth and throat. Providing throat lozenges or warm saline gargles can help alleviate this discomfort.
C. Nausea: Although nausea can occur after a procedure, it is less common than a sore throat after gastric endoscopy. Monitoring and treating nausea is important but not as specific to the procedure as a sore throat.
D. Headache: A headache is not a typical post-procedure issue for a gastric endoscopy and is less relevant to this procedure than sore throat.

A. Assign the UAP to provide care for another client and assume full care of the client. B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Remind the UAP to apply a fitted respirator mask before entering the client's room.

Correct Answer is D

Explanation

A. Assign the UAP to provide care for another client and assume full care of the client: This action is excessive since the UAP is using appropriate personal protective equipment for the situation.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: While important, it is not the immediate concern here.
C. Review the need for the UAP to wear a face mask while in close contact with the client: A face mask is needed, but the correct type of mask for influenza is a fitted respirator.
D. Remind the UAP to apply a fitted respirator mask before entering the client's room: Influenza requires the use of a fitted respirator mask (N95) in addition to gloves and gown to prevent droplet transmission

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The nurse who working in the emergency department is obtaining 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 important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In providing nursing care for a client after gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?

Correct Answer is B

Explanation

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

Correct Answer is D

Explanation

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