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There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
- A. Cut around blood stains to remove clothing.
- B. Place each item of clothing in a separate paper bag.
- C. Allow clothing to dry.
- D. Refrain from documenting client statements.
- E. Place bullets in a sterile container.
Correct Answer: B
Rationale: To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.
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The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
- A. Anorexia.
- B. Tachycardia.
- C. Weight gain.
- D. Cold skin.
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
- A. Check the patient-controlled analgesia (PCA) pump function.
- B. Adjust the epidural catheter.
- C. Assess vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.
A 36-year-old male with lymphoma is assessing a client who reports distress 9 days after chemotherapy. Because of the risk for septic shock, the nurse should assess the client for which cluster of symptoms?
- A. Flushing, decreased oxygen saturation, mild hypotension.
- B. Low-grade fever, chills, tachycardia.
- C. Elevated temperature, oliguria, hypotension.
- D. High-grade fever, normal blood pressure, increased respirations.
Correct Answer: C
Rationale: Elevated temperature, oliguria, and hypotension are critical signs of septic shock, a life-threatening complication in chemotherapy patients due to neutropenia.