A nurse in the emergency department is collecting 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 crucial for the nurse to implement?

Pay close attention to the client’s account of the event.

Report the incident to the university’s security department.

Prevent the client from showering until all evidence is collected.

Ascertain the client’s personal reaction to the reported rape.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Paying close attention to the client’s account of the event is important, but it is not the most crucial intervention. The nurse should listen empathetically and nonjudgmentally to the client’s account, but this should not take precedence over ensuring the client’s physical well- being and preserving evidence.
Choice B rationale

Reporting the incident to the university’s security department is not the most crucial intervention. While it is important to report the incident to the appropriate authorities, the nurse’s primary responsibility is to the client. Ensuring the client’s physical well-being and preserving evidence should take precedence.
Choice C rationale
Preventing the client from showering until all evidence is collected is the most crucial intervention. Showering can destroy valuable physical evidence that can be used in the investigation and prosecution of the crime.
Choice D rationale
Ascertaining the client’s personal reaction to the reported rape is important, but it is not the most crucial intervention. The nurse should provide emotional support and refer the client to counseling services, but this should not take precedence over ensuring the client’s physical well-being and preserving evidence.

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Correct Answer is D

Explanation

Choice A rationale

Keeping the head of the bed raised 45 degrees can help improve lung expansion and reduce the risk of aspiration, which is particularly important for patients who are intubated or receiving enteral nutrition. However, it is not the most important intervention for a patient with septic shock.
Choice B rationale
Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or parenteral nutrition, as these can increase blood glucose levels. However, it is not the most important intervention for a patient with septic shock.
Choice C rationale
Assessing the warmth of the patient’s extremities can provide information about peripheral perfusion and may be useful in monitoring the patient’s response to treatment. However, it is not the most important intervention for a patient with septic shock.
Choice D rationale
This is the correct answer. Maintaining strict intake and output is crucial in managing a patient with septic shock. Fluid balance is a key component of managing septic shock, and accurate intake and output measurements are essential for guiding fluid resuscitation and assessing the patient’s response to treatment.

A. Determine the presence of ST-elevations or non-ST-elevations on the electrocardiogram B. Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area C. Verify troponin level assessments are scheduled every 3-6 hours for a series of three D. Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%

Correct Answer is D

Explanation

Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.

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A nurse in the emergency department is collecting 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 crucial for the nurse to implement?

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Naxlex Comprehensive Predictor Exams

A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? Select all that apply.

A client with hepatic failure has an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours. What intervention should the nurse include in the plan of care?

A patient with neuroleptic malignant syndrome has been prescribed dantrolene 1.5 mg/kg IV. The patient weighs 132 pounds. The label on the 250 mg vial reads, “Reconstitute with 5 mL sterile water for injection, USP. Reconstitution yields 50 mg/mL.”. How many mL should the nurse administer?

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mg/kg/min. Which intervention should the nurse implement while administering this medication?

A nurse in the emergency department is collecting 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 crucial for the nurse to implement?