A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply. A)Locate and remove any medication patches B)Locate possible medical alert band or necklace C)Remove rings and jewelry and lock in a secure location D)Remove tampon and replace with menstrual pad E)Take out contacts if no presence of eye trauma

Question

Quizplus · Accepted Answer

The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. This includes checking for: Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status (Option B) Contact lenses: Remove to prevent corneal injury (Option E) Medication patches: To prevent drug interactions and determine conditions currently being treated Tampons (in female clients): Remove to prevent toxic shock syndrome or infection (Option D) Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops (Option C) (Option A) Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client. Educational objective: When caring for an unconscious client during admission, the nurse should assess for medical alert devices and any prescriptive materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could harm the client if not removed (eg, tampons, rings/jewelry).

A Female Client Is Admitted to the Emergency Department After