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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
While the color, clarity, and odor of urine can provide important information about a patient’s overall health and hydration status, it is not the most crucial information to obtain before inserting an indwelling urinary catheter.
Choice B rationale
The patient’s ability to increase fluid intake can be important in managing various health conditions, but it is not the most important information to obtain before this procedure.
Choice C rationale
Knowing if a patient has allergies to antiseptic solutions is crucial before inserting an indwelling urinary catheter. Using an antiseptic solution that a patient is allergic to can lead to serious complications.
Choice D rationale
While a previous history of urinary tract infections can inform the care and management of a patient with an indwelling urinary catheter, it is not the most important information to obtain before the procedure.

A. Productive cough B. Respiratory rate of 28 breaths/minute C. Oxygen saturation of 90% on room air D. Heart rate of 101 beats/minute E. Capillary refill of 4 seconds F. Blood pressure of 145/89 mm Hg

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale

A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

Correct Answer is C

Explanation

Correct Answer is ["B","C","D"]

Explanation

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

A male adult is admitted due to an overdose of acetaminophen. After being transferred to the mental health unit, the patient is informed that he has liver damage. What is the most crucial information for the nurse to include in the patient’s discharge plan?

The nurse is preparing a dose of teriparatide for a patient. The medication is labeled as “750 mcg/2.4 mL”. How many mL should the nurse administer to deliver a dose of 60 mcg

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes. Which behaviors should the nurse prioritize for monitoring?

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

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?