Which action is the priority for the forensic nurse examiner (RN-FNE) when caring for a patient who was abducted and gang-raped and is now in serious condition in the emergency department?
Evaluating the patient's level of consciousness (LOC) using the Glasgow Coma Scale
Informing the patient that the RN-FNE cannot act on a patient's behalf
Monitoring vital signs, especially blood pressure and pulse
Assessing the patient's airway
The Correct Answer is D
A. Evaluating the patient's level of consciousness using the Glasgow Coma Scale is important, but it is secondary to ensuring that the airway is open and that breathing is maintained.
B. Informing the patient that the RN-FNE cannot act on the patient's behalf is unnecessary at this point; the priority is immediate medical intervention.
C. Monitoring vital signs, such as blood pressure and pulse, is crucial but secondary to addressing immediate life-threatening conditions like airway compromise.
D. Assessing the patient's airway is the priority because airway compromise is the most critical issue in emergency care. The RN-FNE must stabilize the patient's airway first before proceeding with other assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The Code of Ethics for Nurses offers broad ethical guidelines, but it does not provide specific clinical practice guidelines.
B. The Code does touch on social justice issues, but it is not primarily focused on critiquing societal oppression or domination.
C. While the Code supports good care, it is more about establishing ethical standards rather than providing direct care guidelines.
D. The Code expresses nursing's commitment to society, outlining the profession's ethical standards and obligations toward patients and society as a whole.
Correct Answer is D
Explanation
A. Auscultating the right upper quadrant of the abdomen while injecting air into the tube is an outdated and unreliable method for confirming tube placement. This technique can lead to false positives and is not recommended.
B. Obtaining radiography of the abdomen is a highly accurate method for confirming nasogastric tube placement but is not always the first-line method due to the need for imaging and exposure to radiation. However, it may be used if other methods are uncertain.
C. Auscultating the left upper quadrant of the abdomen while injecting air into the tube is another outdated and unreliable method, similar to auscultating the right upper quadrant.
D. Checking the pH of fluid aspirated from the tube is the most accurate and recommended method. Gastric fluid typically has a pH of 1.5 to 3.5, whereas respiratory or intestinal fluids have higher pH levels. Checking the pH is a simple and reliable way to confirm the placement of the nasogastric tube.
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