Nursing Elites

1. The laws enacted by states to provide immunity from liability to persons who provide emergency care at an accident scene are called:

• A. Good Samaritan laws.
• B. HIPAA.
• C. Patient Self-Determination Act (PSDA).
• D. OBRA.

Correct answer: A

Rationale: The correct answer is Good Samaritan laws. These laws protect individuals who provide voluntary emergency care from being held liable for any unintended injury or harm that may occur during the care. Good Samaritan laws encourage individuals to assist in emergencies without fear of legal repercussions. HIPAA, on the other hand, focuses on safeguarding patient information and privacy, ensuring confidentiality. The Patient Self-Determination Act (PSDA) pertains to a patient's rights to make decisions about their medical treatment and advance directives. OBRA, enacted in the late 1980s, aims to improve the quality of care in nursing homes and enhance residents' quality of life, focusing on nursing home reform and standards, which is not directly related to immunity for emergency care providers.

2. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

• A. grief work facilitation
• B. vital signs monitoring
• C. medication administration: skin
• D. anxiety reduction

Correct answer: A

Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn. Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature. Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity. Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'

3. A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

• A. Asking the client to wiggle their toes
• B. Medicating the client with the prescribed analgesic
• C. Realigning the client
• D. Removing some of the traction weights

Correct answer: C

Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.

4. How far should the enema tube be inserted for a client to have a flatus-reducing enema?

• A. 4 inches.
• B. 6 inches.
• C. 2 inches.
• D. 8 inches.

Correct answer: A

Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema. Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.

5. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action?

• A. Check the client's apical pulse
• B. Check when the last feeding was given
• C. Check the placement of the tube
• D. Check when the last medications were given

Correct answer: C

Rationale: Before administering medications through an NG tube, the nurse must first check the placement of the tube to prevent aspiration. This is done by aspirating gastric contents and measuring the pH. Checking the client's apical pulse is unrelated to NG tube medication administration. Checking when the last feeding was given is important but not a priority before administering medications. Checking when the last medications were given is also not directly related to ensuring the safe administration of medications through an NG tube. Ensuring the correct placement of the tube is crucial to prevent complications such as pulmonary aspiration.

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