A young woman arrives to the Emergency Department and reports that she was raped and stabbed.
What should the nurse do first?

Call the Sexual Nurse Examiner.

Assess vital signs.

Call her parents to ask for permission to treat.

Contact Security in case the perpetrator arrives.

Answer and Explanation

The Correct Answer is B

The nurse should prioritize the physical safety and stability of the patient who has been raped and stabbed.

Assessing vital signs is the first step in determining the patient’s condition and identifying any life-threatening injuries that need immediate intervention.

Choice A is wrong because calling the Sexual Nurse Examiner is not the first action to take.

The Sexual Nurse Examiner is a specially trained nurse who can perform a forensic examination and collect evidence from the patient, but this should be done after ensuring the patient’s physical safety and obtaining consent.

Choice C is wrong because calling her parents to ask for permission to treat her is not necessary or appropriate.

The patient is an adult who can consent to her own treatment unless she is incapacitated or mentally incompetent.

Calling her parents without her permission may violate her privacy and autonomy.

Choice D is wrong because contacting Security in case the perpetrator arrives is not the most urgent action to take.

The nurse should focus on the patient’s needs and not assume that the perpetrator will follow her to the hospital.

Security measures can be taken later if needed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.

Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.

This prevents the person from getting entangled or injured by the restraints.

Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.

Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.

Normal ranges for restraints are:

Check the person at least every 15 minutes
Remove restraints and meet basic needs at least every 2 hours
Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist

A. A client with a fasting blood sugar of 187. B. A client with expiratory wheezing after an albuterol treatment. C. A client who has been called to surgery 2 hours early. D. A client with a blood pressure of 178/90 and needs a dose of atenolol.

Correct Answer is B

Explanation

A client with expiratory wheezing after an albuterol treatment.

This indicates that the client has a severe bronchospasm that is not responding to the medication and may lead to respiratory failure.

The client needs immediate intervention to improve airway patency and oxygenation.

Choice A is wrong because a fasting blood sugar of 187 mg/dL is high but not life- threatening. The normal range for fasting blood sugar is less than 99 mg/dL.

The client may have diabetes or prediabetes and needs further evaluation and treatment, but this is not a priority over choice B.

Choice C is wrong because a client who has been called to surgery 2 hours early may need some preparation and education, but this is not an urgent situation.

The client can wait until the nurse has assessed the other clients.

Choice D is wrong because a blood pressure of 178/90 mmHg is elevated but not critical. The normal range for blood pressure is less than 120/80 mmHg.

The client needs a dose of atenolol, which is a beta

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 young woman arrives to the Emergency Department and reports that she was raped and stabbed. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When using wrist restraints, which of these statements is correct?

Correct Answer is D

Explanation

A nurse has received report on four clients. What client should the nurse see first?

Correct Answer is B

Explanation

A nurse who serves on an infection control committee is assessing the adequacy of environmental controls against infection. What does the nurse know to be the first line of defense in medical asepsis?

The nurse talks with a client who is a widower of six years and who misses his wife. What is the best statement by the nurse to encourage the client to express his feelings?

A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations. What is the priority action?

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

A client has not voided eight hours after surgery and says to the nurse, “I don’t think I can urinate.” What should be the first action for the nurse?

Which instructions should a nurse give to a client prior to obtaining a throat culture?

A nurse is developing a plan of care for a client diagnosed with constipation. Which nursing interventions should be included in planning? (Select all that apply).

Which instruction should a nurse include in the teaching plan for a client receiving non-steroidal anti-inflammatory drugs (NSAIDS) for the treatment of rheumatoid arthritis?

A young woman arrives to the Emergency Department and reports that she was raped and stabbed.
What should the nurse do first?