A patient is admitted to the emergency department with multiple wounds inflicted by an unknown assailant. What action should the nurse take?
1. Clean and dress the wounds as soon as initial assessment is completed.
2. Dispose of bloody clothing in a biohazard bag.
3. Change gloves often during patient care.
4. Keep evidence in the patient's room until it is released to authorities.
3
Rationale 1: Wound care should not be performed until photographs of the wounds have been taken.
Rationale 2: The clothing may be evidence and should not be discarded.
Rationale 3: To preserve any evidence on the patient's body, the nurse should change gloves often during care. This helps to prevent transferring evidence from one wound to another. It also helps protect evidence from environmental contamination in the ED.
Rationale 4: The evidence must be secured so that the chain of custody is maintained. Evidence bags should be placed in a secure, locked area.
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What flush solution is recommended for intravenous catheters larger than 24 gauge?
a. Saline b. Heparin c. Alteplase d. Heparin and saline combination
The nurse works with several clients who routinely take nutritional supplements. The nurse is aware that which of the following statements about vitamins is true?
A) Most Americans do not consume adequate amounts of thiamin, riboflavin, and niacin. B) Most Americans do not consume adequate amounts of vitamin C. C) Taking large doses of vitamin A is potentially harmful. D) Because of the potential health benefits, beta-carotene supplements are routinely recommended.
Comfort care is also called
A) aggressive care. B) holistic care. C) palliative care. D) condolence care.
A patient is a candidate for a xenograft valve. The nurse emphasizes that this type of valve does not require anticoagulant therapy, but will require which intervention?
a. Replacement in about 7 to 10 years b. An exercise program to develop collateral circulation c. Daily temperature checks to watch for signs of rejection d. Frequent monitoring for pulmonary edema