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Questions 164

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Question 1 of 5

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.

Correct Answer: A,C

Rationale: Accepting money negates Good Samaritan protection, and failure to apply direct pressure could be considered negligent care.

Question 2 of 5

The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk is pink. What is the nurse's initial action?

Correct Answer: D

Rationale: Acrocyanosis is normal in newborns. Skin-to-skin contact promotes thermoregulation and bonding.

Question 3 of 5

A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?

Correct Answer: A

Rationale: Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100 g). This level is low enough to foster the patient’s own erythropoiesis without enlarging the spleen.

Question 4 of 5

A 54-year-old male is admitted to the cardiac unit with chest pain radiating to the jaw and left arm. Which enzyme would be most specific in the diagnosis of a myocardial infarction?

Correct Answer: D

Rationale: CK-MB (creatine phosphokinase muscle bond isoenzyme) is the most specific for a myocardial infarction. Troponin is also extremely reliable. Answers A, B, and C are nonspecific to myocardial infarctions, so they are incorrect.

Question 5 of 5

The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.

Correct Answer: A,D,E

Rationale: Milk reduces iron absorption, metronidazole with alcohol can cause severe reactions, and diphenhydramine can worsen closed-angle glaucoma.

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