Question

A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key and asks the client to wiggle their fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?

Answer 1

Correct Answers:

Good Samaritan immunity.

Rationale :

🔷 The nurse provided assistance at the scene of an accident in good faith, without gross negligence, and left after EMS arrived—meeting the criteria for Good Samaritan protection.

🔷 These laws are designed to protect healthcare providers from liability when offering emergency care without compensation.

🔷 The nurse’s actions were appropriate, and there’s no indication of harm or abandonment.

🔷 The care provided was within the nurse’s scope of practice, and transfer to EMS was timely.

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Answer 2

Correct Answers:

Puts on new gloves when entering a client's room.

Rationale :

🔷 Standard precautions require the use of clean gloves during direct client care, especially if contact with body fluids is anticipated.

🔷 Putting on a new pair of gloves per room ensures infection control and protects both client and caregiver.

🔷 Sterile gloves are not needed unless performing a sterile procedure.

🔷 Gloves stored in pockets may be contaminated, defeating their protective purpose.

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Answer 3

Correct Answers:

Bears body weight on the palms of hands during the crutch gait.

Rationale :

🔷 Correct crutch walking involves weight-bearing on the palms, not the axilla, to avoid nerve damage (brachial plexus injury).

🔷 The client must use arm strength to support weight while moving, ensuring proper body mechanics.

🔷 Teaching this technique protects against complications and promotes safe, independent ambulation.

🔷 This is a hallmark indicator of correct three-point gait usage.

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Answer 4

Correct Answers:

Observe the client's skin and mucous membranes.

Rationale :

🔷 During nasopharyngeal suctioning, it’s critical to monitor for hypoxia or oxygen desaturation, which may show as cyanosis or pallor.

🔷 Skin and mucous membranes offer visible clues to oxygen status and respiratory distress.

🔷 Suctioning is invasive and can cause oxygen drops, so frequent assessments are needed.

🔷 This helps identify if the client needs rest between passes or additional oxygen support.

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Answer 5

Correct Answers:

Ensure bevel of the needle is pointing up.

Rationale :

🔷 For intradermal injections, the needle must be inserted with the bevel facing up to create a small bleb or wheal.

🔷 This method ensures the medication is delivered just under the epidermis.

🔷 It also reduces leakage and facilitates even distribution.

🔷 This technique is essential for allergy testing and TB screening.

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Answer 6

Correct Answers:

Begin with questions that are less sensitive in nature.

Rationale :

🔷 Gradually progressing from general to personal topics builds rapport and client comfort.

🔷 Asking sensitive questions too early may cause defensiveness or withdrawal.

🔷 This approach supports a therapeutic relationship, making the client more likely to disclose.

🔷 It's a foundational interviewing strategy in health history collection.

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Answer 7

Correct Answers:

Raises the head of the bed to 60 degrees.

Rationale :

🔷 Although raising the HOB is important, 60 degrees may not be adequate for high-risk clients.

🔷 Best practice is at least 75–90 degrees upright and supervised feeding.

🔷 This incomplete positioning may still allow aspiration risk, especially post-CVA.

🔷 Further education is needed to ensure airway protection during meals.

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Answer 8

Correct Answers:

Verify placement of pulse oximeter.

Rationale :

🔷 An SpO₂ reading of 89% may reflect improper sensor placement, poor circulation, or motion artifact.

🔷 The first action is to confirm that the reading is accurate before increasing oxygen.

🔷 Increasing O₂ without verification may delay addressing the true cause of hypoxemia.

🔷 Always assess equipment integrity first in oxygenation concerns.

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Answer 9

Correct Answers:

Establish a regular time for going to bed and getting up.
Avoid drinking caffeinated beverages late in the day.

Rationale :

🔷 B. Establish a regular bedtime and wake-up time promotes circadian rhythm consistency and improved sleep quality.

🔷 E. Avoiding caffeine late in the day helps reduce stimulation and sleep latency, especially in older adults.

🔷 Other options like alcohol or sedatives can disrupt REM cycles or lead to dependence.

🔷 Sleep hygiene is foundational in addressing insomnia in elderly clients.

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Answer 10

Correct Answers:

Determine apical pulse rate and rhythm.

Rationale :

🔷 A potassium level of 7.5 mEq/L is critically high and may cause life-threatening cardiac dysrhythmias.

🔷 Monitoring apical pulse and rhythm helps detect signs of bradycardia, irregularity, or peaked T-waves.

🔷 Cardiac monitoring should begin immediately due to risk of ventricular fibrillation or asystole.

🔷 This is a high-priority emergency assessment.

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QLexNursing

2 :
The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

3 :
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

4 :
Which client assessment should the nurse perform during nasopharyngeal suctioning?

5 :
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

6 :
The nurse is interviewing a client with lower abdominal pain and dysuria and needs to question the client about sexual activity. Which approach is best for the nurse to use?

7 :
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

8 :
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

9 :
An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply..

10 :
When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

QLexNursing

2 : The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

3 : The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

4 : Which client assessment should the nurse perform during nasopharyngeal suctioning?

5 : The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

6 : The nurse is interviewing a client with lower abdominal pain and dysuria and needs to question the client about sexual activity. Which approach is best for the nurse to use?

7 : The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

8 : The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

9 : An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply..

10 : When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

2 :
The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

3 :
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

4 :
Which client assessment should the nurse perform during nasopharyngeal suctioning?

5 :
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

6 :
The nurse is interviewing a client with lower abdominal pain and dysuria and needs to question the client about sexual activity. Which approach is best for the nurse to use?

7 :
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

8 :
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

9 :
An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply..

10 :
When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]