A nurse is caring for a client who was sexually assaulted. An assessment of the client indicates that they might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?
Where did the assault occur?
Do you give us permission to call the police?
Who was the individual who assaulted you?
What day and time did the assault take place?
The Correct Answer is C
A. While knowing the location of the assault may be relevant for police reports, it does not directly pertain to the client’s health and potential exposure to HIV.
B. Permission to contact the police is important for legal reasons, but the priority is to address the client's health needs first.
C. Identifying the individual who assaulted the client is critical for assessing the risk of HIV exposure and determining the need for post-exposure prophylaxis (PEP). This question directly impacts the client’s immediate health care.
D. Understanding the day and time of the assault is useful for legal documentation but is less critical than assessing potential exposure to HIV.
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Correct Answer is D
Explanation
A. Increasing the infusion rate may exacerbate the patient's symptoms and does not address the potential toxicity from the furosemide.
B. Normal potassium levels indicate that potassium supplementation is unnecessary and does not address the dizziness and ringing in the ears, which could suggest ototoxicity from furosemide.
C. While reassurance can help, the patient's symptoms indicate a potential adverse reaction to the medication that should not be ignored.
D. Stopping the furosemide infusion and notifying the provider is the most appropriate action due to the risk of ototoxicity and the need for further evaluation of the patient's symptoms.
Correct Answer is D
Explanation
A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.