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.

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Correct Answer is A

Explanation

Insert a sterile needle and aspirate 3 to 5 mL of urine into the syringe. This is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter because it ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

Choice B is wrong because it does not use sterile technique and it does not collect fresh urine. The urine in the drainage bag may have been sitting there for a long time and may not reflect the current condition of the patient’s urinary tract.

Choice C is wrong because it does not use sterile technique and it flushes the catheter with sterile water, which may dilute the urine and alter its composition.

Choice D is wrong because it does not use sterile technique and it collects urine from the drainage bag, which may be contaminated or stale.

A. “Since I am taking Clozaril, I will need to have bloodwork performed weekly for six months.”. B. “I will urinate less when taking Clozaril, and that is normal.”. C. “I will use the Clozaril as needed for delusions and hallucinations.”. D. “Clozaril is now available over-the-counter and in a generic form.”.

Correct Answer is A

Explanation

“Since I am taking Clozaril, I will need to have bloodwork performed weekly for six months.” This indicates that the client understands that Clozaril (clozapine) is an antipsychotic medication that can affect the immune system and cause a serious blood disorder called agranulocytosis. The client needs to have regular blood tests to monitor the white blood cell count and prevent infections.

Choice B is wrong because Clozaril can cause urinary retention, not decreased urination. The client should be advised to report any difficulty or pain when urinating.

Choice C is wrong because Clozaril is not a PRN medication. It should be taken regularly as prescribed by the doctor to maintain a therapeutic level and prevent relapse of psychotic symptoms.

Choice D is wrong because Clozaril is not available over the counter or in a generic form. It is a controlled substance that requires a special program and a certified pharmacy to dispense it.

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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

Which is the most appropriate action when obtaining a sterile urine specimen from an indwelling urinary catheter?

Correct Answer is A

Explanation

Which response by the client indicates that medication instruction by the RN has been effective?

Correct Answer is A

Explanation

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

Which client assessment should a nurse immediately report to the health care provider?

Which statement, if made by an older client diagnosed with urinary incontinence, indicates a need for further teaching?

A health care provider has ordered vital signs every 4 hours. The client’s 8:00 AM temperature was 99° F (37.2° C). At 10 AM, the client reported chills. A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?

A health care provider prescribes one ounce of an elixir medication for a client. How many milliliters (mL) of medication should the nurse instruct the client to take during discharge teaching?

A client is started on furosemide 80 mg every morning. Which lab result needs to be reported to the health care provider?

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

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