Nokea
The nurse is caring for the body and personal belongings of a client who died as a result of multiple gunshot wounds. Which actions should the nurse take to properly secure and handle legal evidence? Select all that apply.
- A. Place paper bags on the hands and feet.
- B. Give the clothing and wallet to the family.
- C. Cut clothing along the seams, avoiding bullet holes.
- D. Collect all personal items, including items from clothing pockets.
- E. Place wet clothing and personal belongings in a labeled, sealed plastic bag.
- F. Do not allow family members, significant others, or friends to be alone with the client.
Correct Answer: A,C,D,F
Rationale: Basic rules for securing and handling evidence include minimally handling the body of a deceased person; placing paper bags on the hands and feet and possibly over the head of a deceased person (protects trace evidence and residue); placing clothing and personal items in paper bags (plastic bags can destroy items because items can sweat in plastic); cutting clothes along seams, avoiding areas where there are obvious holes or tears; and collecting all personal items, including items from clothing pockets. Evidence is never released to the family to take home, and family members, significant others, or friends are not allowed to be alone with the client because of the possibility of kindizing any existing legal evidence.
You may also like to solve these questions
The post-myocardial infarction client is scheduled for a technetium-99 m ventriculography (multigated acquisition [MUGA] scan). The nurse should ensure that which item is in place before the procedure?
- A. A Foley catheter
- B. Signed informed consent
- C. A central venous pressure (CVP) line
- D. Notation of allergies to iodine or shellfish
Correct Answer: B
Rationale: MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary. A Foley catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergy to iodine and shellfish is not a concern.
To ensure that the client self-administers medications safely in the home, which action plan should the nurse implement?
- A. Perform a pill count of each prescription bottle at every home visit.
- B. Instruct the client to double up on a medication when a dose is missed.
- C. Provide information on the purpose of all the prescribed medications.
- D. Ask the client to explain and demonstrate self-administration procedures.
Correct Answer: D
Rationale: To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self-administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually it is not acceptable to double up on missed medication and conducting a pill count on each visit is unrealistic and disrespectful.
A client is being admitted to the hospital after receiving a radiation implant after being diagnosed with cervical cancer. Which priority action should the nurse implement in the care of this client?
- A. Encourage the family to visit.
- B. Admit the client to a private room.
- C. Place the client on protective isolation.
- D. Encourage the client to take frequent rest periods.
Correct Answer: B
Rationale: The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation. Protective isolation is unnecessary; rather, individuals other than the client need to be protected. Frequent rest periods are a helpful general intervention but are not a priority for the client in this situation.
The nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse should implement immediate care for a client with which injury?
- A. Fractured tibia
- B. Penetrating abdominal injury
- C. Bright red bleeding from a neck wound
- D. Open massive head injury, resulting in deep coma
Correct Answer: C
Rationale: The client with bright red (arterial) bleeding from a neck wound is in 'immediate' need of treatment to save the client's life. This client is classified as an emergent (life-threatening) client and would wear a color tag of red from the triage process. A green or 'minimal' (nonurgent) designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. The client with a penetrating abdominal injury would be tagged yellow and classified as 'urgent,' requiring intervention within 60 to 120 minutes. A designation of 'expectant' would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded 'black' in the triage process. The client who is color-coded 'black' is given supportive care and pain management but is given definitive treatment last.
The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the LPN because of client needs that cannot be met by UAP? Select all that apply.
- A. A client requiring frequent suctioning
- B. A client requiring a dressing change to the foot
- C. A client requiring range-of-motion exercises twice daily
- D. A client requiring reinforcement of teaching about a diabetic diet
- E. A client on bed rest requiring vital sign measurement every 4 hours
- F. A client requiring collection of a urine specimen for urinalysis testing
Correct Answer: A,B,D
Rationale: Delegation is the transferring to a competent individual the authority to perform a nursing task. When the nurse plans client assignments, he or she needs to consider the educational level and experience of the individual and the needs of the client. The LPN is trained to perform all the tasks indicated in the options; the clients who have needs that cannot be met by the UAP are those requiring suctioning, a dressing change, and reinforcement of teaching about a diabetic diet. UAP are trained to perform range-of-motion exercises, measure vital signs, and collect a urine specimen.