Exhibits

A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.

Inform the dient that they cannot refuse medical examination

Report laboratory findings to law enforcement.

Prepare to administer prophylaxis for STIs.

Assess for thoughts of self-harm

Recommend emergency contraception to the client.

Answer and Explanation

Correct Answer : C,D,E

A. Inform the client that they cannot refuse medical examination: All patients, including those who have been sexually assaulted, have the legal right to refuse any part of the examination. Informed consent is essential.
B. Report laboratory findings to law enforcement: Unless there is a mandatory reporting law in effect for that specific jurisdiction, results and disclosures require the client's consent before being shared with law enforcement.
C. Prepare to administer prophylaxis for STIs: Clients who have experienced sexual assault are at risk for sexually transmitted infections. Early administration of prophylactic antibiotics is a standard, time-sensitive intervention.
D. Assess for thoughts of self-harm: Sexual assault survivors are at increased risk for depression, suicidal ideation, and PTSD. A mental health assessment should be conducted immediately to ensure safety.
E. Recommend emergency contraception to the client: If pregnancy is a potential concern, emergency contraception should be offered within a limited time window after the assault, regardless of the client’s current hCG level.

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Correct Answer is A

Explanation

A. “Rise slowly when getting out of bed.": Furosemide is a loop diuretic that can cause orthostatic hypotension due to fluid loss. Teaching the client to rise slowly helps prevent dizziness and falls associated with sudden position changes.
B. "Eat foods that are high in sodium.": Sodium intake should be limited in clients with heart failure, as high sodium can worsen fluid retention and counteract the effects of diuretics like furosemide.
C. “Taking furosemide can cause you to be overhydrated.": Furosemide increases urine output and poses a risk of dehydration, not overhydration. Monitoring fluid balance is essential during treatment.
D. "Taking furosemide can cause your potassium levels to be high.": Furosemide can lead to hypokalemia (low potassium), not hyperkalemia. Clients may need potassium supplementation or dietary adjustments to prevent electrolyte imbalance.

A. “I can start the medication 30 minutes earlier.” B. “I have up to 2 hours after the usual scheduled time to give you this medication." C. “I can adjust the time and schedule for when it's convenient for you." D. “I can infuse the medication at a faster rate.”

Correct Answer is A

Explanation

A. “I can start the medication 30 minutes earlier.”: Most facilities allow a 30-minute window before or after the scheduled administration time for IV antibiotics like vancomycin. Administering it more than 30 minutes early may interfere with therapeutic drug levels and proper dosing intervals.
B. “I have up to 2 hours after the usual scheduled time to give you this medication.”: While some medications may allow a late administration window, vancomycin requires precise timing to maintain therapeutic levels and prevent resistance. Delays beyond 30 minutes are generally not appropriate.
C. “I can adjust the time and schedule for when it's convenient for you.”: Medication schedules, especially for antibiotics, are based on pharmacokinetics and infection control. Altering times for convenience can compromise treatment effectiveness and safety.
D. “I can infuse the medication at a faster rate.”: Infusing vancomycin too quickly increases the risk of adverse reactions such as Red Man Syndrome. It must be administered over a prescribed minimum time to reduce complications.

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Exhibits A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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Exhibits

A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.