Nokea
Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply.
- A. The nurse accepts money from the victim
- B. The nurse does not accompany the victim on the ambulance
- C. The nurse does not apply direct pressure to the artery
- D. The nurse knows the victim from college
- E. The victim dies after reaching the hospital
Correct Answer: A,C
Rationale: Accepting money negates Good Samaritan protection, and failure to apply direct pressure could be considered negligent care.
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Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
- A. Assist with plans for any clients discharged
- B. Provide basic hygiene care to all clients on the unit
- C. Assess a client after an acute myocardial infarction
- D. Gather the vital signs of all clients on the unit
Correct Answer: B
Rationale: Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.
The nurse is talking with a client whose spouse recently attempted suicide. The client states, 'If I had not intervened, my spouse would have died. I cannot believe this is happening.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do not focus on the negative. You should try to focus on helping your spouse get better.
- B. I imagine that this is overwhelming. Tell me more about how you are feeling right now.
- C. Do you have any relatives or close friends who can help support you through this?
- D. Has your spouse been experiencing worsening depression recently?
Correct Answer: B
Rationale: Acknowledging the client's feelings and encouraging expression provides emotional support.
The nurse is discussing management of nocturnal enuresis with the parent of a 10-year-old client who has had little response to behavioral interventions. The parent tells the nurse, 'My child wants to go to overnight camp in several months but is afraid of being teased by other children if an accident occurs.' Which of the following responses would be most appropriate for the nurse to make?
- A. The condition will be resolved by then if you are consistent with bedtime routines.
- B. We can ask your child's health care provider about trying a medication that may be helpful.
- C. You could offer to send disposable training pants for your child to wear if needed.
- D. You should consider sending your child to day camp instead of overnight camp.
Correct Answer: B
Rationale: Medications like desmopressin may help manage enuresis for events like camp, addressing the child's concerns.
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.
- A. I should rinse my mouth with water before collecting the sputum.
- B. I will be careful not to touch the inside of the specimen cup or lid.
- C. I will inhale deeply a few times and then cough forcefully.
- D. It is best to collect the sputum mid-day when my secretions are loose.
- E. It is helpful if I am sitting upright when I collect the sputum.
Correct Answer: A,B,C,E
Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.
A woman who is 32 weeks gestation comes to her physician's office. Which finding is of most concern to the office nurse?
- A. Trace of glucose in the urine
- B. Weight gain of 4 lb in one month
- C. Swelling around the client's eyes
- D. Ankle and foot edema
Correct Answer: C
Rationale: Periorbital swelling at 32 weeks suggests preeclampsia, a serious condition requiring immediate evaluation. Trace glucose, 4-lb weight gain, or ankle edema are less concerning.