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 B
Explanation
A. A blood pressure of 130/90 mm Hg is slightly elevated but not immediately life-threatening and is not typically an urgent triage concern.
B. Respirations of 6 breaths/min indicate severe respiratory distress and inadequate ventilation, which is a critical finding that requires immediate attention. This finding justifies placing the patient in the urgent triage category.
C. Body temperature of 104°F (40°C) may indicate infection or other serious conditions, but it is not as immediately life-threatening as significantly impaired respiratory function.
D. Heart rate of 70 beats/min is normal and does not indicate an urgent need for care.
Correct Answer is ["104"]
Explanation
Convert days to hours:
- 1 day 24 hours/day = 24 hours 1
Calculate the hourly rate:
- 2500 mL / 24 hours = 104.1666... mL/hour
Round to the nearest whole number:
- 104 mL/hour
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