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 experience 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 experience
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NCLEX NCLEX-PN

NCLEX-PN Quizlet 2023

1. 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?

Correct answer: The clothing of a trauma victim is potential evidence with legal implications.

Rationale: The correct answer is C. 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 it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.

2. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:

Correct answer: reinforce the dressing.

Rationale: Serosanguinous drainage is expected after a classic cholecystectomy resection. The appropriate intervention is to reinforce the dressing to maintain pressure and promote clot formation. Changing the dressing prematurely increases the risk of infection as it disturbs the wound. Applying an abdominal binder is not indicated as it can interfere with visualizing the dressing and assessing for any signs of bleeding or infection. Notifying the physician is not necessary at this point unless there are signs of excessive bleeding or other concerning symptoms.

3. The LPN has been given assignments by the RN. Which assignment should the LPN question as being beyond the scope of the LPN?

Correct answer: The LPN is assigned to care for a woman with newly diagnosed leukemia who will be receiving her initial dose of chemotherapy.

Rationale: The LPN should be able to recognize when an assignment is beyond their scope of practice. Administering chemotherapy for leukemia is not within the scope of practice for the LPN, and this assignment should be questioned. Choices A, B, and C are within the scope of practice for an LPN. Reinforcing teaching on self-administration of insulin, assisting with discharge instructions on dressing changes, and caring for a client being discharged with no medications are all appropriate tasks for an LPN.

4. Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?

Correct answer: Assist the mother to identify what she believes is preventing her success and what she can do to improve.

Rationale: The priority intervention for a mother who feels incompetent in parenting a teenage daughter is to assist her in identifying the factors contributing to her feelings of inadequacy and help her develop better coping and mothering skills. This approach focuses on addressing the mother's emotional needs and empowering her to improve her situation. Option A is incorrect as it focuses on the daughter's discipline, which may not be the root cause of the mother's feelings. Option B is irrelevant as it focuses on improving her husband, not her parenting skills. Option D is incorrect as it shifts the focus solely to the daughter's behavior, neglecting the mother's emotional needs and self-improvement.

5. The nurse is educating a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

Correct answer: “This infection can be transmitted via intercourse even when you do not feel ill.”

Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It is crucial to educate the patient that the infection can be transmitted via intercourse even when asymptomatic to prevent its spread. Choice A is incorrect as sitting on toilet seats without protection does not transmit genital herpes. Choice B is incorrect because oral sex can transmit the virus. Choice D is also incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.

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