The nurse is concerned that the chain of custody for evidence collected in the emergency department may have been breached
Which situation would support the nurse's concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The evidence was placed at the foot of the patient's bed while the nurse who collected it went to get an evidence bag.
2. The nurse who collected the evidence sealed it in a bag and placed a label on the bag.
3. The nurse who collected the evidence left it at the busy nurses' station for law enforcement authorities to pick up.
4. The nurse handed the sealed and labeled evidence bag to a law enforcement officer.
5. The wet clothing was hung in the utility room to dry before bagging.
1,3,5
Rationale 1: If the person who collected the evidence leaves it unattended in an unlocked area, the chain of custody has been breached.
Rationale 2: Sealing the evidence in a bag and labeling the bag helps to maintain the chain of custody.
Rationale 3: If the nurse did not lock the evidence in a secure area and it was left unattended in the nurse's station, the chain of evidence was breached.
Rationale 4: The chain of evidence went from the nurse to the law enforcement officer without being breached.
Rationale 5: If the clothing was left unattended in the utility room, the chain of custody was breached.
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The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation
The patient tells the nurse that he doesn't want to take any more pills and asks what could happen if he doesn't fill the prescription. What is the nurse's best response? a. "You could have a stroke." b. "Your kidneys could fail." c. "You could develop heart failure." d. "You could go into respiratory failure."
The client with diabetes is visually impaired and wants to know if syringes can be prefilled and stored for use later. What is the nurse's best response?
A. "Yes, prefilled syringes can be stored for up to 3 weeks in the refrigerator in a vertical position with the needle pointing up." B. "Yes, prefilled syringes can be stored for up to 3 weeks in the refrigerator, placed in a horizontal position." C. "Insulin reacts with plastic, so prefilled syringes must be made of glass." D. "No, insulin cannot be stored for any length of time outside of the container."
The presence of which skin assessment finding, if noted on an older adult patient, should cause the nurse to suspect a premalignancy?
a. Numerous small red papules on the chest and back b. An oozing, rough, reddish macule on the ear c. An irregularly shaped mole on the face or shoulders d. Brown, greasy lesions on the neck
Which is an example of an actual NANDA nursing diagnosis?
a. Risk for Impaired Skin Integrity Related to Inability to Change Positions b. Potential for Enhanced Nutrition c. Fluid Volume Deficient Related to Nausea and Vomiting d. Risk for Infection Related to Indwelling Urinary Catheter