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 A
Explanation
A. Respiratory acidosis is correct because the patient has a low pH (acidosis) and elevated PaCO₂, indicating hypoventilation as the primary cause.
B. Metabolic alkalosis is incorrect because bicarbonate is within the normal range, and there is no metabolic compensation.
C. Respiratory alkalosis is incorrect because alkalosis would present with a high pH and low PaCO₂, the opposite of this scenario.
D. Metabolic acidosis is incorrect because bicarbonate is normal, ruling out a metabolic cause.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Blank 1
Prepare for defibrillation: The client is unresponsive and has ventricular tachycardia. This indicates a life-threatening arrhythmia. If a patient with VTach is pulseless, the treatment is defibrillation.
Blank 2
Vtach (Ventricular tachycardia): The ECG tracing shows a rapid, wide-complex tachycardia, which is the hallmark of ventricular tachycardia.
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