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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Limiting all nutrients is not recommended for patients on dialysis. While certain nutrients like potassium and phosphorus may need to be restricted, dialysis patients usually require adequate nutrition, especially protein, to support healing and prevent malnutrition.
B. Ensuring an adequate amount of protein is correct. Dialysis patients often experience protein loss through dialysis and need additional protein to prevent catabolism and muscle wasting. Protein intake should be carefully monitored to meet their nutritional needs while avoiding excessive waste buildup.
C. Increasing fluids is not typically advised for dialysis patients, as they often have fluid restrictions due to reduced kidney function and the risk of fluid overload.
D. Encouraging potassium-rich foods is not advisable for patients with renal disease, particularly if they are on dialysis, as they often have issues with potassium retention, which could lead to dangerous hyperkalemia.

A. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min B. Patient with a temperature of 100.5° F who is asleep but easily roused C. Patient with respiratory rate of 10 breaths/min who is breathing deeply D. Patient with a respiratory rate of 8 breaths/min who is snoring

Correct Answer is D

Explanation

A. Blood pressure and heart rate are not indicators of opioid overdose; these values are within a normal range and do not suggest respiratory depression.
B. A temperature of 100.5°F and sleepiness are concerning but not life-threatening in isolation; the patient is easily aroused, which suggests they are not in respiratory distress.
C. A respiratory rate of 10 breaths/min is low, but if the patient is breathing deeply, they may still be compensating, and further monitoring is necessary.
D. A respiratory rate of 8 breaths/min with snoring is indicative of severe respiratory depression, a life-threatening side effect of opioid use. Immediate intervention is necessary.

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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?

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Naxlex Comprehensive Predictor Exams

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