Question 1

What should a nurse document in a patient's chart?

Accepted Answer

Answer reason: Objective assessment data, like vital signs, must be documented. The other choices describe unsafe practices (recapping a needle, injecting into a reddened area) or information to review, rather than being specifically charted as a new entry.

Question 2

The nursing staff are sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks the unit secretary has acquired immunodeficiency syndrome. The nursing assistant then tells the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated?

Accepted Answer

Answer reason: The assistant made a spoken, defamatory statement about another person. Oral defamation is slander; libel is written defamation.

Question 3

The nursing staff are sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks the unit secretary has acquired immunodeficiency syndrome. The nursing assistant proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated?

Accepted Answer

Answer reason: The assistant made a spoken defamatory statement about the secretary; spoken defamation is slander. Libel is written defamation; assault is a threat; negligence is a failure to use reasonable care.

Question 4

A 2-year-old child is admitted to the hospital with a diagnosis of pneumonia and is given antibiotics, fluids, and oxygen. The child's temperature continues to rise until it reaches 103°F (39.4°C). The nurse calls the physician at the mother's request, but the physician sees no cause for alarm or for a change in treatment, even though the child has a history of convulsions during previous periods of high fever. Although concerned, the nurse takes no further action. Later, the child has a convulsion that results in neurologic impairment of the left arm and leg. Legally?

Accepted Answer

Answer reason: With a known history of febrile seizures and a high fever, the nurse had a legal duty to advocate for the child and escalate the concern up the chain of command when the physician dismissed it. Failure to further question or to seek additional orders placed the child at risk and constituted negligence.

Question 5

A nurse has been convicted of theft after the head nurse discovered the narcotics count was inaccurate on a number of occasions. The hospital must report the nurse's conviction to which database?

Accepted Answer

Answer reason: Criminal convictions and other adverse actions against health professionals must be reported to the Healthcare Integrity and Protection Data Bank (now integrated into the NPDB). The other listed databases are not required reporting entities.

Question 6

The majority of disciplinary actions by state boards of nursing pertain to?

Accepted Answer

Answer reason: State boards most commonly discipline for impairment issues (e.g., substance use or diversion) affecting safe practice; malpractice or negligence are largely civil matters, and practicing without a license is less frequent.

Question 7

The primary purpose of regulating nursing practice is to protect?

Accepted Answer

Answer reason: Nurse Practice Acts and boards of nursing regulate licensure and practice primarily to ensure public safety by ensuring that practitioners are competent and ethical.

Question 8

A nurse is interviewing for a position at a major hospital. Which information regarding liability insurance should the nurse keep in mind when asking questions about hospital versus private liability insurance?

Accepted Answer

Answer reason: Private liability insurance protects nurses in personal practice, volunteer settings, and circumstances where the hospital’s policy does not fully cover individual liability.

Question 9

A nurse has been named in a lawsuit. The best evidence a nurse can use to protect herself in a court of law is?

Accepted Answer

Answer reason: The medical record is the legal document of nursing care; thorough, timely documentation provides the strongest evidence of what was done. Certification, manager reports, or merely verifying orders are not primary legal defenses.

Question 10

A nurse is preparing a client for a surgical procedure. Which action best demonstrates compliance with legal and ethical requirements for informed consent?

Accepted Answer

Answer reason: Nurses do not obtain informed consent but may serve as witnesses. The legal nursing responsibility is to verify the client’s identity, ensure the signature is voluntary, and confirm the client was appropriately informed by the provider. Explaining risks and benefits is the provider’s legal duty, not the nurse’s.

Question 11

The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with?

Accepted Answer

Answer reason: Harm resulted from a nurse’s failure to meet professional standards in medication administration; this is professional negligence, i.e., malpractice. Tort is a broad category, negligence is general (nonprofessional), and assault is a threat without physical contact.

Question 12

The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with?

Accepted Answer

Answer reason: Falsifying documentation by recording a medication as given when it was not is intentional deception and constitutes fraud.

Question 13

What is the primary purpose of advance directives in client care?

Accepted Answer

Answer reason: Advance directives state the client’s treatment preferences to guide care when the client cannot communicate, protecting client rights and autonomy.

Question 14

The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?

Accepted Answer

Answer reason: The donor card represents the client’s legal consent. The nurse should respect the client’s wishes and involve the trained organ-procurement staff to discuss donation with the family, rather than threaten, coerce, or delay.

Question 15

What should the nurse explain to an elderly client about the handling of her diamond rings before same-day cataract surgery?

Accepted Answer

Answer reason: Valuables should be removed before surgery and secured per policy: inventoried, placed in a valuables envelope, signed by the client, and stored in the hospital safe. Taping rings, locking them in the narcotics box, or having staff personally hold them are improper and unsafe.

Question 16

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signature. The client asks the nurse for assistance in obtaining a witness to the will. The most appropriate response to the client is which of the following?

Accepted Answer

Answer reason: Nurses must follow facility policy when clients request assistance with legal documents such as a living will. Nurses typically should not serve as witnesses unless permitted by policy; consulting the supervisor ensures compliance with legal and ethical standards.

Question 17

Which of the following is true about documentation in medical records?

Accepted Answer

Answer reason: The medical record serves as a legal document. Errors should not be erased or covered; they are corrected with a single-line strike-through and proper notation. Nurses cannot sign entries written by others, and judgmental terms should be avoided.

Question 18

A client is admitted to a psychiatric–mental health unit on an emergency involuntary status. What is the minimum length of time the client will remain hospitalized?

Accepted Answer

Answer reason: Emergency involuntary admission typically allows detention for evaluation for 48–72 hours; thus the minimum period is 48 hours.

Question 19

A client refuses to follow the physician’s orders and leaves the hospital against medical advice (AMA). What risk is the client assuming?

Accepted Answer

Answer reason: Clients who leave AMA and have decision-making capacity assume responsibility for outcomes related to their condition; it is not a legal violation or negligence by the provider.

Question 20

A majority of disciplinary actions by the state boards of nursing pertain to?

Accepted Answer

Answer reason: State boards most commonly discipline for impairment (often substance use/diversion), which directly affects safe practice and licensure; malpractice/negligence are primarily civil matters.

Question 21

The code of ethics for nurses is composed and published by?

Accepted Answer

Answer reason: The Code of Ethics for Nurses is authored and published by the American Nurses Association. AMA is for physicians, NLN focuses on nursing education, and NIH is a federal research agency.

Question 22

During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for?

Accepted Answer

Answer reason: Libel is written defamation; slander is spoken. The nurse documented a defamatory suspicion in writing that was seen by another person, fitting libel.

Question 23

A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of?

Accepted Answer

Answer reason: Threatening to give an unwanted injection constitutes assault (threat of harmful or offensive contact). Battery would require actually administering it without consent.

Question 24

When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a?

Accepted Answer

Answer reason: Clothing evidence should be air-dried and stored in paper bags to prevent moisture buildup and mold that can degrade DNA; plastic or sealed containers trap moisture and compromise evidence integrity.

Question 25

The doctor accidently cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with?

Accepted Answer

Answer reason: Malpractice is professional negligence by a healthcare provider—failure to meet the standard of care resulting in patient harm. Negligence and tort are broader terms; assault involves threat, not unintended surgical injury.

Question 26

Which information should be reported to the state Board of Nursing?

Accepted Answer

Answer reason: An ongoing incorrect narcotic count suggests diversion or mishandling by licensed personnel, a potential violation of nursing practice that must be reported to the state Board of Nursing. The other options are facility/administrative or CNA performance issues handled internally, not by the Board.

Question 27

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should?

Accepted Answer

Answer reason: The charge nurse should address suspected falsification through facility policy and appropriate disciplinary action within the organization. Calling the BON, terminating employment, or pursuing a tort are not immediate or within the charge nurse’s authority. A formal reprimand (with documentation and further investigation) is the most appropriate option given.

Question 28

A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?

Accepted Answer

Answer reason: Voluntarily admitted psychiatric patients have the right to request discharge. The nurse should first notify the HCP to evaluate safety and determine appropriate discharge procedures or hold if needed.

Question 29

According to the Ethiopia’s abortion Law, May 2005: Termination of pregnancy recognized by medical institution within the period permitted by the profession not punishable where?

Accepted Answer

Answer reason: Ethiopia’s 2005 abortion law allows termination for rape or incest, risk to the mother’s health/life, fetal deformity, physical or mental disability, and for minors; therefore all listed conditions apply.

Question 30

A new nursing graduate indicates in charting entries that he is a licensed registered nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in a charge of?

Accepted Answer

Answer reason: Documenting oneself as a licensed RN without licensure is intentional misrepresentation for professional status, which constitutes fraud. Malpractice and negligence involve unintentional failure to meet standards; tort is a broad category.

Question 31

The nurse asked the client if he has an advance directive. The reason for asking the client this question is?

Accepted Answer

Answer reason: Advance directives help prevent conflict or confusion among family members and ensure that the client’s wishes are followed if they lose decision-making capacity.

Question 32

During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse’s first action should be to?

Accepted Answer

Answer reason: Controlled substance discrepancies must be reported immediately to the nursing supervisor per institutional legal policy.

Question 33

The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention is the BEST action by the nurse manager?

Accepted Answer

Answer reason: Suspected impairment is an employment and legal issue. The manager should follow policy and consult HR to ensure proper documentation, due process, and ADA considerations. Confrontation, gathering gossip without the employee, or pressuring resignation are inappropriate.

Question 34

Which of the following entries on a client's progress notes is the MOST complete?

Accepted Answer

Answer reason: This entry is objective, measurable, and specific, meeting legal and documentation standards. The other options use vague terms (seems, adequate) or omit details such as route, time, and response to medication.

Question 35

A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate INITIAL action?

Accepted Answer

Answer reason: Wasting narcotics requires a witnessed disposal; a recurrent pattern without a witness suggests potential diversion. The appropriate initial action is to follow chain of command and report to the nurse manager rather than co-sign, confront personally, or counsel a peer.

Question 36

All nurses are licensed to practice by their?

Accepted Answer

Answer reason: In the U.S., licensure for nurses is granted by state boards of nursing, which are state governmental agencies, not local or federal entities or professional associations.

Question 37

A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include?

Accepted Answer

Answer reason: Appropriate documentation includes recording actions taken to ensure safety—adding the suspected agent to the allergy list and noting provider notification. Nurses should avoid assigning causation (2) or prescribing treatment (4). Although objective details like time/circumstances should be charted, the critical documentation for patient safety is allergy notation and provider notification.

Question 38

The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which of the following actions would the nurse take?

Accepted Answer

Answer reason: When a prescription appears unsafe and the prescriber cannot be reached, the nurse must not administer the medication and should follow the chain of command by contacting the nursing supervisor to resolve the order. Do not give the ordered dose or alter the dose without clarification.

Question 39

A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The most appropriate response by the nurse educator is?

Accepted Answer

Answer reason: Employer policies primarily protect the institution and may not fully cover the nurse, especially for actions outside scope or employment. Nurses are advised to carry personal malpractice insurance to protect their own legal and financial interests.

Question 40

A hospitalized client tells the nurse that a living will is being prepared and that the layer will be bringing the will to the hospital today for witness signature. The client asks the nurse for assistance in obtaining a witness to the will. The most appropriate response to the client is which of the following?

Accepted Answer

Answer reason: Nurses should not serve as witnesses for a client’s will. The appropriate action is to refer the request to the nursing supervisor/administration to follow facility policy and state law for obtaining proper witnesses.

Question 41

The nurse has made an error in documenting an assessment finding on a client's record; to correct the error, the nurse corrects the error by?

Accepted Answer

Answer reason: Proper legal documentation requires drawing a single line through the mistaken entry, dating and initialing it, then entering the correct information. Erasing or using whiteout alters the record; a late entry is for omitted documentation, not error correction.

Question 42

The nurse is working in a long-term care facility and administering medication to assigned clients. A client refuses to take the prescribed medication, and the nurse threatened the client and tells the client that if the medication is not taken orally, then restrains will be applied and the medication will be given by injection. The statement by the nurse constitutes which legal tort?

Accepted Answer

Answer reason: Threatening to apply restraints and inject medication if the client refuses constitutes assault (threat of harmful or unwanted contact). Battery would require actual unauthorized touching.

Question 43

A nurse has been in the peer assistance program voluntarily after being charged with drug abuse on the nursing unit. Which statement is true about this nurse's ability to practice?

Accepted Answer

Answer reason: Alternative-to-discipline/peer assistance programs allow monitored return to practice with restrictions, commonly limiting nurses to day shift and prohibiting overtime; critical care is usually restricted, drug screening does not remove restrictions, and licensure is not revoked if compliant.

Question 44

The client responds when the nurse calls the client by name. After giving the client a medication, the nurse realizes that it is the wrong client. The physician is notified, and the nurse documents no adverse reactions to the medication. What should the nurse understand about the possibility of being sued for malpractice?

Accepted Answer

Answer reason: A malpractice claim requires duty, breach, causation, and damages. Because the wrong-client medication caused no harm, the damages element is absent, so a malpractice suit would not be valid.

Question 45

A nurse is interviewing for a position at a major hospital. Which information regarding liability insurance should the nurse keep in mind when asking questions about hospital versus private liability insurance?

Accepted Answer

Answer reason: Employer policies primarily protect the institution; if the hospital pays for damages due to a nurse’s negligence, it may seek indemnification and countersue the nurse. Options 1 and 2 are incorrect, and 3 is overly broad.

Question 46

The day shift nurse receives report for a critically ill client who has pneumonia and is on a ventilator. The departing nurse shares the vital signs with the day nurse and reports that the temperature and blood pressure are within normal limits. When the day shift nurse performs an assessment, the client's temperature is 104.8° F. After checking the previous shift's vital signs, the nurse notes that the last time the temperature was taken was at midnight. It was now 8 am and the patient begins to seize. The nurse on duty knows?

Accepted Answer

Answer reason: A critically ill, ventilated client required frequent temperature monitoring. The failure to assess temperature for 8 hours allowed severe hyperthermia to progress, followed by a seizure, showing a cause-and-effect link between the breach and harm (causation). Foreseeability existed, duty was present, and calling for firing is inappropriate.

Question 47

A 15-year-old is taken to the emergency room of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks if the adolescent has been immunized against tetanus. The reply is affirmative. Penicillin is administered, and the adolescent is sent home with instructions to return if there is any change in the wound area. A few days later, the adolescent is admitted to the hospital with a diagnosis of tetanus. Legally?

Accepted Answer

Answer reason: For a puncture wound, the nurse must verify the date and completeness of tetanus immunization and provide indicated prophylaxis (booster and/or TIG). Simply asking if immunized and giving penicillin is inadequate; the assessment and treatment did not meet the standard of care.

Question 48

A client arrives in the emergency room and is assessed by the nurse. The client is staggering, confused, and verbally abusive. The client complains of a headache from drinking alcohol and is asking for medication. The nurse explains to the client that the physician will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse obtains leather restraints and threatens to place the client in the restraints. With which of the following can the client legally charge the nurse as a result of the nursing action?

Accepted Answer

Answer reason: Threatening to place a client in restraints creates fear of harmful or offensive contact, which is assault. Battery requires actual touching; negligence and invasion of privacy do not apply.

Question 49

The nurse has made an error in documenting an assessment finding on a client's records: to correct the error. The nurse corrects the error by?

Accepted Answer

Answer reason: Correct documentation practice is to draw a single line through the error, initial and date it, and enter the correct information. Erasing or using whiteout is not permitted; a late entry is for omitted notes, not for correcting an error.

Question 50

The 87 year-old women is brought to the emergency room for treatment of a fractured arm. On physical assessment the nurse notes old and new ecchymotic areas on the client's chest and legs. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which of the following is the most appropriate nursing response?

Accepted Answer

Answer reason: Elder abuse must be reported by the nurse as a mandated reporter. The nurse should inform the client of the legal obligation to report rather than promise confidentiality, discuss with the abuser, or blame the victim.

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What should a nurse document in a patient's chart?

A nurse has been convicted of theft after the head nurse discovered the narcotics count was inaccurate on a number of occasions. The hospital must report the nurse's conviction to which database?

The majority of disciplinary actions by state boards of nursing pertain to?

The primary purpose of regulating nursing practice is to protect?

A nurse is interviewing for a position at a major hospital. Which information regarding liability insurance should the nurse keep in mind when asking questions about hospital versus private liability insurance?

A nurse has been named in a lawsuit. The best evidence a nurse can use to protect herself in a court of law is?

A nurse is preparing a client for a surgical procedure. Which action best demonstrates compliance with legal and ethical requirements for informed consent?

The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with?

The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with?

What is the primary purpose of advance directives in client care?

The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?

What should the nurse explain to an elderly client about the handling of her diamond rings before same-day cataract surgery?

Which of the following is true about documentation in medical records?

A client is admitted to a psychiatric–mental health unit on an emergency involuntary status. What is the minimum length of time the client will remain hospitalized?

A client refuses to follow the physician’s orders and leaves the hospital against medical advice (AMA). What risk is the client assuming?

A majority of disciplinary actions by the state boards of nursing pertain to?

The code of ethics for nurses is composed and published by?

During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for?

A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of?

When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a?

The doctor accidently cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with?

Which information should be reported to the state Board of Nursing?

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should?

A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?

According to the Ethiopia’s abortion Law, May 2005: Termination of pregnancy recognized by medical institution within the period permitted by the profession not punishable where?

A new nursing graduate indicates in charting entries that he is a licensed registered nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in a charge of?

The nurse asked the client if he has an advance directive. The reason for asking the client this question is?

During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse’s first action should be to?

The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention is the BEST action by the nurse manager?

Which of the following entries on a client's progress notes is the MOST complete?

A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate INITIAL action?

All nurses are licensed to practice by their?

A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include?

The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which of the following actions would the nurse take?

A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The most appropriate response by the nurse educator is?

The nurse has made an error in documenting an assessment finding on a client's record; to correct the error, the nurse corrects the error by?

A nurse has been in the peer assistance program voluntarily after being charged with drug abuse on the nursing unit. Which statement is true about this nurse's ability to practice?

A nurse is interviewing for a position at a major hospital. Which information regarding liability insurance should the nurse keep in mind when asking questions about hospital versus private liability insurance?

The nurse has made an error in documenting an assessment finding on a client's records: to correct the error. The nurse corrects the error by?

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