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Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing is the property of another and must be treated with care.
- B. Such care facilitates repair and salvage of the clothing.
- C. The clothing of a trauma victim is potential evidence with legal implications.
- D. Such care decreases trauma to the family members receiving the clothing.
Correct Answer: C
Rationale: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident.
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Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.
The nurse teaches the client with relapsing-remitting MS about glatiramer. Which information addressed by the client indicates that the nurse's teaching has been effective? Select all that apply.
- A. Keep the medication vial refrigerated until it is to be used.
- B. Glatiramer is given by injection into the subcutaneous tissue.
- C. Rotate injection sites and wait a week before using a site again.
- D. The thigh and abdomen are the best subcutaneous injection sites.
- E. Syringes are washed, air dried, and reused until the needle is dull.
Correct Answer: A,B,C
Rationale: A: Glatiramer is used to delay the progression of MS. To maximize the therapeutic effects of glatiramer, it should be refrigerated and reconstituted correctly. B: Glatiramer is only administered subcutaneously; accidental IV administration must be avoided. C: Injection sites are rotated to prevent skin breakdown or lumps at the injection sites. D: Appropriate subcutaneous injection sites for glatiramer include the thigh, back of the hip, abdomen, and upper arm. E: Used syringes should be placed in a puncture-resistant container for proper disposal. Syringes and needles should not be reused.
The nurse is caring for the client with CA receiving piroxicam. Which instruction is most important for the nurse to include in the medication teaching plan?
- A. Take piroxicam with food to decrease stomach irritation.
- B. If your pain is severe, you can take another piroxicam pill.
- C. Lie down until piroxicam is effective for controlling your pain.
- D. You can take ginkgo for an energy boost when taking piroxicam.
Correct Answer: A
Rationale: A: Piroxicam (Feldene) should be taken with food and a full glass of water to prevent gastric irritation and possible bleeding. B: Piroxicam is administered in a once-daily dose, and additional doses should not be taken. C: Because of the gastric irritation and possible reflux, the client should sit upright after taking piroxicam. D: Ginkgo interacts with piroxicam, increasing the risk for bleeding.
The client is prescribed medications on hospital admission. Four days later the client's serum creatinine level, which was normal at admission, is now 3.7 mg/dL. The nurse should contact the HCP regarding a dosage change for which medication?
- A. Ceftriaxone
- B. Insulin glargine
- C. Diltiazem
- D. Furosemide
Correct Answer: A
Rationale: A: The nurse should contact the HCP regarding ceftriaxone (Rocephin). Ceftriaxone, a third-generation cephalosporin antibiotic, is 33% to 67% excreted in the urine unchanged. Dosage reduction or increased dosing interval is recommended in renal insufficiency because ceftriaxone is nephrotoxic and can further damage the kidneys. B: Insulin glargine (Lantus) is partially metabolized at the site of injection to active insulin metabolites and partially metabolized by the liver, the spleen, the kidney, and muscle tissue; no dose reduction is necessary unless serum glucose levels fluctuate. C: Diltiazem (Cardizem) is mostly metabolized by the liver; no dose reduction is necessary. D: Furosemide (Lasix) is 30% to 40% metabolized by the liver with some nonhepatic metabolism and renal excretion as unchanged medication; no dose reduction is necessary.
The nurse is working with the family whose child is taking atomoxetine for ADHD. Which instructions should the nurse include when teaching the parents? Select all that apply.
- A. Provide stimulation because atomoxetine causes sedation.
- B. Administer atomoxetine immediately after eating a meal.
- C. Administer atomoxetine at least 6 hours before bedtime.
- D. Weigh the child weekly to monitor for unintended weight loss.
- E. Consult with the prescriber before giving cold or allergy medication.
Correct Answer: B,C,D,E
Rationale: Atomoxetine (Strattera) should be taken after meals, at least 6 hours before bedtime, with weekly weight monitoring and caution with OTC medications.