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Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care?
- A. The Health Insurance Portability and Accountability Act.
- B. The State Nurse Practice Act.
- C. The Emergency Rendering Aid Act.
- D. The Good Samaritan Act.
Correct Answer: D
Rationale: The Good Samaritan Act protects nurses providing emergency care voluntarily, limiting malpractice liability. HIPAA, Nurse Practice Act, or fictional acts don’t apply.
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Which client would be most likely to complete an advance directive?
- A. A 55-year-old Caucasian person who is a bank president.
- B. A 34-year-old Asian licensed practical nurse.
- C. A 22-year-old Hispanic lawn care worker.
- D. A 65-year-old African American retired cook.
Correct Answer: D
Rationale: Older adults (e.g., 65-year-old) are more likely to complete ADs due to increased awareness of mortality and health issues, regardless of ethnicity or profession.
The nurse is teaching a class on chronic pain to new graduates. Which information is most important for the nurse to discuss?
- A. The nurse must believe the client's report of pain.
- B. Clients in chronic pain may not show objective signs.
- C. Alternate pain-control therapies are used for chronic pain.
- D. Referral to a pain clinic may be necessary.
Correct Answer: A
Rationale: Believing the client’s pain report is critical, as pain is subjective, per pain management guidelines. Objective signs, therapies, or referrals are secondary.
The intensive care nurse is caring for a deceased client who is an organ donor, and the organ donation team is en route to the hospital. Which statement would be an appropriate goal of treatment for the client?
- A. The urinary output is 20 mL/hr via a Foley catheter.
- B. The systolic blood pressure is greater than 90 mm Hg.
- C. The pulse oximeter reading remains between 88% and 90%.
- D. The telemetry shows the client in sinus tachycardia.
Correct Answer: B
Rationale: Maintaining systolic BP >90 mm Hg ensures organ perfusion, a key goal for donation. Urine output, oximetry, or tachycardia are less critical post-death.
The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with leukemia who has a hemoglobin of 6 g/dL.
- B. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.
- C. The client diagnosed with colon cancer who needs the colostomy irrigated.
- D. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.
Correct Answer: A
Rationale: Hemoglobin of 6 g/dL indicates severe anemia, requiring complex monitoring and transfusion, best handled by an experienced nurse. Hypoxia, colostomy care, or behavior are less acute.
The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?
- A. The nurse tells the client civilian clothes can be worn on the unit.
- B. The nurse allows the client to have family visits during visiting hours.
- C. The nurse delivers unopened mail and packages to the client.
- D. The nurse listens to the client talking on the telephone to a friend.
Correct Answer: D
Rationale: Eavesdropping on a client’s phone call violates privacy rights, per civil liberties. Allowing clothes, visits, or mail respects client autonomy.