Question 1

This standard is based on the basic principle established by the U.S. Supreme Court in the 1976 landmark case Estelle v. Gamble.?

Accepted Answer

Answer reason: A. Access to care Estelle v. Gamble established that deliberate indifference to serious medical needs of incarcerated people violates the Eighth Amendment, creating a constitutional duty to provide necessary healthcare. The central standard derived from this case is ensuring timely, appropriate medical evaluation and treatment rather than withholding or unreasonably delaying care. Other options (inmate labor, autonomy, privacy) may be relevant to correctional health ethics but are not the primary legal principle set by this case.
Category reason: This question tests a legal/rights-based standard for healthcare delivery (constitutional duty to provide care), aligning with nursing management responsibilities related to legal rights and obligations.

Question 2

Being on time, meeting deadlines and completing all scheduled duties is what virtue?

Accepted Answer

Answer reason: Fidelity is the ethical principle of keeping commitments and being faithful to one’s professional responsibilities. Punctuality, meeting deadlines, and completing assigned duties reflect reliability and follow-through on obligations to patients, colleagues, and the organization. Autonomy concerns honoring a client’s right to make decisions, not work performance. Veracity is truth-telling, and confidentiality is protecting private information, neither of which primarily addresses timeliness and duty completion.

Question 3

A male patient complained because his schedule surgery was cancelled because of earthquake. The hospital personnel may be excused because of?

Accepted Answer

Answer reason: In negligence and liability principles, an unavoidable extraordinary event (act of God) can excuse nonperformance or delay when it is beyond the control of the facility and its staff. An earthquake is a classic example of a force majeure event that can necessitate cancellation of elective procedures for safety and resource reallocation. This directly fits the scenario because the cancellation results from an external disaster rather than a breach of duty by personnel. By contrast, respondeat superior concerns employer liability for an employee’s acts, and res ipsa loquitur applies when harm implies negligence from the nature of the event, neither of which explains disaster-driven cancellation.

Question 4

Breastfeeding is being enforced by milk code or?

Accepted Answer

Answer reason: This item tests knowledge of the governing legal framework that regulates breastfeeding promotion and the marketing of breastmilk substitutes. EO 51 is the Philippine “Milk Code,” which establishes restrictions on advertising, promotion, and distribution of infant formula and related products to protect breastfeeding. R.A. 7600 relates to rooming-in and breastfeeding support in facilities but is not the milk code itself. The other laws listed address different legal topics and do not regulate milk substitute marketing.

Question 5

The nurse in an inpatient mental health unit is aware of the importance of managing sexual behavior among clients. Which statement is accurate regarding the standard protocol of managing sexual behavior on adult psychiatric inpatient units?

Accepted Answer

Answer reason: In adult psychiatric inpatient settings, sexual contact between clients is not permitted because true consent is often impaired by acute mental illness, intoxication, cognitive limitations, or power differentials, creating high risk for exploitation and assault. Unit policy typically requires staff to set clear limits, separate clients, and document and report concerns to maintain safety and meet legal/ethical duties. Framing sexual behavior as therapeutic is unsafe because it ignores boundary violations and the potential for trauma and litigation. While care should generally be least restrictive, preventing patient-to-patient sexual activity is a standard safety restriction due to the predictable risk of harm.

Question 6

Disposal of medical records in government hospital/ institutions must be done in close coordination with what agency?

Accepted Answer

Answer reason: Medical record disposal in government facilities is a regulated health-information governance activity that must follow national health policies on confidentiality, retention, and authorized destruction. The Department of Health is the primary agency overseeing standards for hospital operations and health records management in public institutions, including guidance on proper disposal processes. Coordinating with DOH supports compliance with privacy safeguards and medico-legal requirements that protect patients and the institution. In contrast, agencies like the MMDA or BIR do not set clinical documentation and health-record disposal standards for hospitals.

Question 7

If a nurse forcibly inserts a nasogastric tube against a patient's wishes, the nurse can be held liable for?

Accepted Answer

Answer reason: Forcibly inserting an NG tube despite the patient’s expressed wishes meets the elements of intent and lack of consent, making it an intentional tort. Negligence/malpractice generally involve a breach of the standard of care causing harm, not an intentional act done without consent. The key issue here is violation of the patient’s right to refuse treatment, which turns the act into an assault/battery-type liability even if no physical injury occurs.

Question 8

If nurse administers an injection to a patient who refuses that injection, she has committed?

Accepted Answer

Answer reason: Battery is the actual unauthorized touching or procedure (giving the injection), and assault is the threat or act that creates fear of unwanted contact. In this scenario, the client explicitly refused, so proceeding is an intentional tort rather than an unintentional error. Negligence/malpractice generally involve a breach of the standard of care causing harm, not a consent violation as the primary issue.

Question 9

Which of the following is not a value essential for a professional nurse?

Accepted Answer

Answer reason: Human dignity, social justice, and integrity are core ethical commitments reflected in nursing codes of ethics and professional standards. Dependence is not an essential professional value because nursing practice promotes patient autonomy, empowerment, and self-management rather than fostering reliance on the nurse. In exam terms, anything that contradicts autonomy and professional accountability is the best choice for “not essential.”.

Question 10

At 5:00 pm, the nurse notes that the last entry in a patient’s chart was at 9:00 am. The nurse on the previous shift did not complete the chart and did not sign the nurses’ notes. Which of the following actions by the nurse is BEST?

Accepted Answer

Answer reason: Documentation must be timely, accurate, and reflect the ongoing plan of care so that current caregivers have reliable information for safe decisions. Obtaining a handoff/report from the prior nurse addresses missing clinical information immediately and supports continuity of care while also prompting appropriate follow-up for the incomplete note and missing signature. Leaving blank space or withholding charting creates opportunities for errors, late additions, or altered records and can compromise patient safety and legal integrity of the chart. The oncoming nurse should document their own assessments/interventions contemporaneously, while seeking clarification from the previous shift to ensure the record is complete and clinically coherent.

Question 11

When documenting information in a client's medical record, the nurse should?

Accepted Answer

Answer reason: Legal documentation must be attributable, complete, and legally defensible so that accountability for each entry is clear. Signing each entry with the nurse’s signature and professional title verifies authorship and helps maintain an accurate, auditable health record. Errors should never be erased; the correct approach is to follow agency policy for correcting entries (e.g., single line through error, date/time, and initials) to preserve the integrity of the record. Pencil and leaving blank lines create opportunities for alteration and are not acceptable documentation practices.

Question 12

The client diagnosed with schizophrenia is refusing to take a prescribed psychotropic medication. The nurse attempts to persuade the client to comply with the HCPS orders. Under what circumstance could the client be forced to take medication?

Accepted Answer

Answer reason:  A patient can be medicated against their will only under narrowly defined legal/ethical conditions, most commonly when there is an imminent risk of serious harm to self or others and less-restrictive measures are ineffective. An explicit, credible threat to kill staff indicates immediate danger and supports emergency treatment to protect safety. Fixed delusions alone do not justify forced medication without dangerousness or a court/administrative order. Wanting to leave or describing a past suicide attempt does not by itself establish current imminent risk requiring involuntary medication.

Question 13

What guideline is IMPORTANT in relation to incident report (IR) ? it is ______?

Accepted Answer

Answer reason: The patient’s chart should contain objective clinical assessment findings and the care provided, not institutional process documents. Including an incident report in the chart can create discoverable documentation that is not necessary for continuity of care and may increase legal exposure. A common pitfall is thinking the report belongs wherever routine patient records are stored; instead, it is handled per facility policy through designated reporting channels separate from the chart.

Question 14

When a nurse is tried under criminal law, the nurse is being brought to trial by?

Accepted Answer

Answer reason: Criminal law addresses offenses against the public, so the government (state) prosecutes on behalf of the community rather than a private party. In criminal proceedings, the case is titled with the state or people versus the accused, reflecting that the harmed party is the public order and safety. A “plaintiff” and their lawyer are features of civil litigation seeking damages, not criminal prosecution. Organizations or individuals may report or be victims, but they do not prosecute the criminal case; the state does.

Question 15

You have taken the vital signs for your patient. They are normal for the patient. What should you do next?

Accepted Answer

Answer reason: When vital signs are normal for that specific patient, the appropriate next step is to record them in the designated location so the interdisciplinary team can trend values and detect subtle changes. Reporting to the provider is not required for expected/normal findings unless there is a new change, abnormal trend, or specific reporting parameter. Writing on scrap paper creates a risk for lost information, transcription errors, and breaches of standards for documentation.

Question 16

A nurse enters a client's room and finds her lying on the floor near the bathroom door. As the nurse provides assistance, the client states, "I thought I could get up on my own." What information must the nurse document in this situation?

Accepted Answer

Answer reason: Recording the client’s condition as found (location, position, visible injuries, level of consciousness) and using quotation marks for the client’s exact statement preserves accuracy and supports legal/clinical communication. The nurse should avoid speculation or conclusions about causation, blame, or “why” the event occurred unless directly observed. Explanations of how the fall happened or editorializing about what the client “should have” done are nonobjective and can be inaccurate if the nurse did not witness the fall.

Question 17

The medication order reads, “Give ondansetron (Zofran) 4 mg, 30 minutes before beginning chemotherapy to prevent nausea.” The nurse notes that the route is missing from the order. What is the nurse’s best action?

Accepted Answer

Answer reason: Safe medication administration requires a complete order including route, and administering via an assumed route is a preventable medication error. Ondansetron can be given by multiple routes (e.g., PO, IV), and the correct choice depends on the prescriber’s intent and the patient’s clinical status, so the missing element must be verified. Choosing IV or PO based on convenience or fear of vomiting bypasses the provider order and increases risk of wrong-route administration. Waiting for rounds unnecessarily delays antiemetic prophylaxis before chemotherapy; the priority is timely clarification now to ensure safe, accurate administration.

Question 18

Civil registries are important sources of data. Which law requires registration of births within 30 days from the occurrence of the birth?

Accepted Answer

Answer reason:  Civil registration laws establish the legal duty and timeframe for reporting vital events to ensure accurate population statistics and legal identity documentation. The statute that governs the registration of births (and other vital events) and sets the required reporting period of within 30 days is the Civil Registry Law. This is codified as Republic Act 3753, which provides the basis for timely birth registration requirements. The other choices are either different issuances or incorrect/irrelevant law numbers for the specified 30-day birth registration rule.

Question 19

Which of the following professionals can sign the birth certificate?

Accepted Answer

Answer reason: A public health nurse and a rural health midwife commonly attend or document community births and are recognized as appropriate certifiers in many local health systems. The municipal health officer also has statutory authority to certify vital events and oversee civil registration processes. Since each listed role may be legally empowered to certify births depending on jurisdiction and context, the most inclusive option is the best answer.

Question 20

When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response?

Accepted Answer

Answer reason: Unlawfully restraining or confining a client without legal justification or the client’s consent meets the definition of false imprisonment. By contrast, negligence and malpractice are typically unintentional torts involving a breach of the duty to act as a reasonably prudent nurse, resulting in harm. “Breach of duty” is an element of negligence/malpractice analysis, not a named intentional tort itself.

Question 21

A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to?

Accepted Answer

Answer reason: Promptly alerting the provider activates the clinical chain needed for urgent risk assessment, possible involuntary hold, and coordination of higher-level care while maintaining appropriate documentation and supervision. Simply recommending inpatient care is not sufficient as a first step because it does not ensure immediate containment of risk or timely authorization for emergency interventions. Maintaining confidentiality is not appropriate when there is a credible threat of self-harm, and contacting family without following proper emergency procedures and privacy rules is not the safest initial action.

Question 22

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: The nurse should not co-sign a waste that was not witnessed because that constitutes inaccurate controlled-substance documentation and can implicate the co-signer. Reporting promptly allows a supervisor to secure medications, initiate required investigation, and follow institutional and regulatory processes for suspected diversion. Direct confrontation or informal counseling is inappropriate as a first step because it can escalate the situation, compromise evidence, and bypass mandatory reporting pathways.

Question 23

Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?

Accepted Answer

Answer reason: A stated threat to self or others triggers the nurse’s duty to protect/safety obligations, which may require notifying appropriate parties per policy (provider, mental health crisis resources, security/law enforcement as indicated). The other situations do not constitute legal authority to disclose protected health information without client consent or a valid legal exception. Even when disclosure is necessary, the nurse should share only the minimum information needed and follow institutional reporting procedures.

Question 24

The provisions of the law for the Americans with Disabilities Act require nurse managers to

Accepted Answer

Answer reason: This aligns with the nurse manager’s role in adjusting work processes or the environment (e.g., scheduling, assistive devices, modified duties) in a way that is feasible and non-discriminatory. The requirement is not to eliminate all hazards in general (a broader safety obligation) but to remove disability-related barriers when reasonable. A common trap is thinking the law requires “all necessary” accommodations; the statutory standard is reasonableness balanced against undue hardship.

Question 25

A fellow nurse who was under a lot of pressure made an inappropriate remark to a patient. She admitted her mistake and made apologies to the patient. This is an example of which of the following?

Accepted Answer

Answer reason: Admitting the mistake and apologizing demonstrates ownership of the error and a commitment to ethical, patient-centered conduct. This aligns with accountability, which includes acknowledging lapses and taking appropriate corrective steps to maintain trust and safety. Autonomy refers to respecting a patient’s right to make decisions, not taking responsibility for a nurse’s behavior. Management/controlling are leadership functions and do not specifically capture personal responsibility for an error.

Question 26

A 19-year-old cancer patient declined treatment. The patient's parents disagreed with his decision, as his parents work in the medical field and feel that the treatment could save his life. As the patient's nurse, which ethical principle best supports the patient's decision?

Accepted Answer

Answer reason: At age 19, the patient is a legal adult, so the nurse should support and protect his self-determination after ensuring he has decision-making capacity and adequate information. Parental disagreement does not override an adult patient’s choices, even when the family believes the decision is medically unwise or life-saving treatment is available. Beneficence focuses on doing good from the clinician’s perspective, but it cannot ethically replace an informed, capable patient’s refusal. The nurse’s role is to advocate for the patient’s expressed wishes and ensure informed refusal is documented and communicated appropriately.

Question 27

A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a registered professional nurse. What group primarily is protected under the regulations of the practice of nursing?

Accepted Answer

Answer reason: Licensure sets minimum standards for education, competency, and safe scope of practice, and it enables discipline when practice is unsafe. While these rules also affect employers and nurses, their purpose is not to shield the profession or institutions from liability but to safeguard patients and anyone receiving care. A common distractor is focusing on “people with health problems,” but nursing regulation protects the broader public, including those at risk for harm from unsafe practice.

Question 28

Nurses are held responsible for the commission of a tort. The nurse understands that a tort is?

Accepted Answer

Answer reason: A tort is a civil wrong (not a criminal offense) that causes harm to a person or property and can lead to liability for damages. This definition correctly captures the civil nature of the wrongdoing directed toward an individual’s rights or property, which is why nurses can be sued for negligence, assault, battery, false imprisonment, or defamation. Option D describes a crime, which is an offense against the public prosecuted by the state, not a tort claim for damages. Option C describes the “reasonable person” standard used to evaluate negligence, but it is not the definition of a tort itself.

Question 29

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan?

Accepted Answer

Answer reason: Assault is defined in many nursing/legal contexts as placing another person in reasonable fear of imminent harmful or offensive contact, which can occur via a threat without physical contact. This fits teaching about child abuse because threatening behavior can constitute assault even if the child is not physically touched. The option describing application of force without lawful justification more closely describes battery, which involves actual physical contact. The remaining options describe other legal concepts (property torts or crimes against the public) rather than assault.

Question 30

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The nurse reports the information to the charge nurse, and the charge nurse does not allow the client to leave. The nurse understands that which represents the legal ramifications associated with the charge nurse’s behavior?

Accepted Answer

Answer reason: Involuntary psychiatric admission permits restricting a client’s freedom of movement when required to protect the client or others and when legal criteria for detention are met. Here the client’s history of extremely violent behavior supports continued holding for safety while the treatment team follows the involuntary commitment process, making the restriction legally justified. False imprisonment requires unlawful restraint without proper authority; the scenario implies lawful authority exists due to involuntary admission status and safety risk. Assault involves threats of harm and slander is a false spoken statement, neither of which is described in the charge nurse’s action of preventing elopement.

Question 31

On a home visit, the nurse finds four young children alone. The youngest of the children has bruises on the face and back and circular burns on the inner aspect of the right forearm. The nurse should?

Accepted Answer

Answer reason: The combination of young children left alone plus patterned injuries (bruising in multiple areas and circular burns suggestive of inflicted injury) meets threshold for immediate reporting. Reporting initiates an urgent safety assessment and legally appropriate intervention pathway while preserving proper documentation and chain of accountability. Actions like transporting the child or taking children to a shelter may be needed only if there is an immediate life-threatening emergency, but they do not replace the legal duty to report and may exceed the nurse’s authority.

Question 32

Several recently licensed registered nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance?

Accepted Answer

Answer reason: " Professional liability insurance is intended to protect the individual nurse’s professional license and provide legal defense for claims arising from professional practice. Employer-provided coverage is primarily designed to protect the organization, and it may not fully cover the nurse’s personal interests or licensing-board/administrative actions. A key value of individual policies is access to legal representation for BON investigations and charges, which are distinct from civil malpractice suits. The idea that carrying insurance makes a nurse “more likely to be sued” is not a reliable or accurate basis for decision-making compared with the concrete coverage benefits of a personal policy.

Question 33

A nurse is preparing to administer medication to a client when they realize that the physician doubled the normal dose by mistake. What should the nurse do next?

Accepted Answer

Answer reason: The core principle is that nurses are legally and ethically responsible for verifying questionable medication orders before administration to prevent patient harm. A clearly incorrect dose requires holding the medication and promptly obtaining clarification/correction from the prescriber, since only the provider can change the order. Calling pharmacy can help with drug information, but it does not resolve an erroneous prescription and can delay correction of the order. Administering the medication despite recognizing a likely error breaches the duty to protect the client and violates safe medication practice.

Question 34

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen?

Accepted Answer

Answer reason: Nurses are legally permitted and expected to initiate urgent, low-risk measures to stabilize airway and breathing when a patient shows acute respiratory compromise. Sudden cyanosis and a change in respirations indicate impaired oxygenation requiring immediate intervention, and delaying to obtain an order could constitute failure to act and increase risk of harm. Oxygen is commonly allowed under nursing scope via standing orders/protocols or as an emergency nursing measure while simultaneously notifying the provider. Calling for an order first is inappropriate when time-sensitive hypoxemia is suspected, whereas withholding due to lack of a prior order prioritizes paperwork over patient safety.

Question 35

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!". The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted?

Accepted Answer

Answer reason: Threatening language and coercion meet the concept of assault, and physically restraining the child without proper clinical justification/authorization constitutes battery. Even though preventing skin injury is a valid goal, restraint must follow policy, require appropriate orders/indications, and be paired with ongoing assessment and documentation. The nurse’s intent and statement indicate punitive intent rather than safe protective care, making the legal interpretation most consistent with assault and battery.

Question 36

Which of the following is considered as a example of intentional tort?

Accepted Answer

Answer reason: Unlawfully restraining or confining a client (physically or by threats) without legal justification fits this definition. Malpractice and negligence are unintentional torts based on deviation from professional standards leading to harm. “Breach of duty” is an element of negligence, not a specific intentional tort category.

Question 37

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident?

Accepted Answer

Answer reason: When defective equipment contributes to patient injury, liability can be shared between the individual who used/applied it and the employer under principles of vicarious liability and negligence. The worn strap suggests a foreseeable equipment hazard that should have been identified and removed from service to prevent harm. Options claiming total exemption or complete exoneration overstate the doctrines involved and ignore the nurse’s independent duty to protect the client from known or discoverable safety risks.

Question 38

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation?

Accepted Answer

Answer reason: Legal responsibility hinges on whether the nurse met the standard of care by performing appropriate assessment and implementing indicated interventions based on available information. The client reported immunizations were up to date, and the wound was cleansed, dressed, and appropriate follow-up instructions were provided, which aligns with reasonable nursing care for a puncture wound. Development of tetanus after the fact does not automatically establish negligence if the nurse acted prudently and within scope using the information obtained at the time. Options implying routine nurse-administered tetanus immunization or incomplete assessment overstate the nurse’s legal duty and ignore that immunization decisions typically require provider orders and confirmation of immunization status.

Question 39

A nurse is removing an indwelling urinary catheter from a client. Which action is appropriate?

Accepted Answer

Answer reason: Accurate documentation is a required part of safe catheter discontinuation because it establishes a clear record for follow-up assessment and accountability. Recording the removal time helps guide monitoring for first void, urinary retention, and post-removal intake/output tracking. Sterile gloves are not required for removal; clean technique is typically sufficient because the catheter is being taken out rather than inserted. Cutting the balloon port is unsafe and can cause trauma if the balloon does not fully deflate, and left-side positioning is not a standard requirement for urinary catheter removal.

Question 40

Which client cannot sign out against medical advice?

Accepted Answer

Answer reason: Acute intoxication can significantly impair cognition and judgment, making capacity unreliable and potentially invalidating an AMA signature at that time. In that situation, the nurse should notify the provider, follow facility policy, and use appropriate safety measures while capacity is assessed. By contrast, a critically ill client (e.g., STEMI) may still have capacity and can leave if competent, and an emancipated minor generally has adult-like authority to consent/refuse care.

Question 41

A competent client in a long-term care facility refuses to take his oral diuretic. The nurse tells him that if the medication isn’t taken, restraints will be applied and the medication will be given by injection. The nurse’s statement constitutes which legal tort?

Accepted Answer

Answer reason: The nurse’s statement threatens forced restraint and an injection if the client refuses, which is coercive and implies nonconsensual contact. Battery would require the actual touching/administration of the injection without consent, which has not occurred yet. Negligence concerns failure to meet a standard of care causing harm, and autonomy is an ethical principle rather than a tort.

Question 42

The nurse is administering medication, and the client states, “I’ve never seen this pill before.” What should the nurse do next?

Accepted Answer

Answer reason: Medication safety requires verifying the “rights” of medication administration whenever there is any discrepancy or client concern. A client stating the pill is unfamiliar is a red flag for a potential medication error, so the nurse should pause and validate the order against the MAR and the medication label before proceeding. This action protects the client and supports the client’s right to safe care and informed decision-making. Reassurance, teaching, or explaining brand differences can be appropriate only after the nurse has confirmed the medication is correct and intended for that client.

Question 43

A client is diagnosed with tuberculosis (TB). In addition to recommending skin testing of the family members, the public health nurse is aware that cases of TB should be reported to which of the following?

Accepted Answer

Answer reason: Tuberculosis is a reportable condition, and notification is made to the local or state health department, which then coordinates investigation and reporting up the public health chain. Direct reporting to the CDC is not the typical required first step for individual clinicians because the CDC receives data via state and local reporting systems. Notifying an infection-control nurse or the client’s physician supports care coordination, but it does not fulfill the mandated public health reporting requirement.

Question 44

A nurse who is working at the health department has been assigned to obtain a sputum culture for possible tuberculosis (TB) from a client. After collecting the specimen, the professional nurse should report positive TB smears or cultures to the health department within which time period?

Accepted Answer

Answer reason: A positive TB smear or culture indicates a reportable condition needing prompt health department action. Reporting within 48 hours aligns with common mandated timelines for urgent communicable-disease notifications, allowing rapid initiation of public health interventions. Waiting a week or longer delays control measures and increases community transmission risk, while 12 hours is not the standard requirement in this context.

Question 45

The nurse suspects that a coworker is working while impaired. Which initial action should be taken by the nurse?

Accepted Answer

Answer reason: Patient safety and professional duty require prompt reporting through the chain of command when a staff member may be impaired. The nurse manager can immediately assess the situation, remove the coworker from patient care if needed, and initiate facility policy (eg, reasonable-suspicion process, documentation, and referral to employee assistance or alternative-to-discipline programs). Direct confrontation risks escalating the situation and does not ensure patients are protected in the moment. Reporting to external agencies or the board is typically not the first step unless required by policy after internal evaluation or if there is immediate danger and no supervisory response.

Question 46

An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. The client falls out of bed while the bed is in high position, with side rails down, and the client unattended. Which charge is the most appropriate for the nurse’s actions?

Accepted Answer

Answer reason: Leaving a post-anesthesia elderly patient unattended in a high bed position with side rails down breaches the expected standard of care and creates a foreseeable fall risk. The resulting fall represents harm linked to that breach, which fits the definition of negligence. This is not battery because there is no intentional unauthorized touching, and it is not willful misconduct because the scenario reflects failure to use due care rather than intentional wrongdoing.

Question 47

While giving the change of shift report to the oncoming night shift nurse, the evening shift nurse smells alcohol on the night shift nurse’s breath. The evening shift nurse should?

Accepted Answer

Answer reason: Patient safety and professional accountability require prompt action when a staff member may be impaired on duty. Reporting through the immediate chain of command initiates an objective assessment and ensures the nurse is removed from patient care if needed, preventing harm and limiting institutional liability. Waiting to gather more signs delays a safety intervention and allows potential errors to occur. Confronting the nurse directly or leaving a note does not ensure timely, documented, and policy-based management of possible impairment.

Question 48

The client does not want chemotherapy, but the family says he should take it. What is the best response by the nurse?

Accepted Answer

Answer reason: A competent adult has the legal and ethical right to refuse treatment, even when family members disagree. The nurse’s priority is to support autonomy by validating that the decision belongs to the client and ensuring it is informed and voluntary. Redirecting to family concerns can introduce coercion and shift the focus away from the client’s preferences and values. Asking about a religious advisor may be appropriate only if the client raises spiritual concerns, and sharing what the nurse would do is nontherapeutic and risks undue influence.

Question 49

A family member is involuntarily admitted to the psychiatric mental health unit. As a psychiatric mental health nurse you know that clients are involuntarily admitted when behavior is driven by mental illness and?

Accepted Answer

Answer reason: Involuntary psychiatric admission is legally justified when a mental illness causes the patient to pose an immediate danger to self or others or results in inability to meet basic needs such that serious harm is likely. An imminent risk of suicide or serious self-injury meets the “danger to self” threshold and requires urgent protection and stabilization. Poor hygiene alone does not usually meet criteria unless it reflects grave disability with unsafe inability to care for self. Medication refusal and expressed anger, by themselves, are generally addressed through capacity assessment, education, and outpatient or voluntary options unless they are linked to imminent dangerousness.

Question 50

A physician prescribes carbamazepine (Tegretol) 1,200 mg by mouth twice daily for a client with trigeminal neuralgia. Which action should the nurse take first?

Accepted Answer

Answer reason: Medication safety and legal responsibility require the nurse to clarify an order that appears unsafe before administration. Carbamazepine dosing for trigeminal neuralgia is typically titrated and generally does not exceed about 1,200 mg/day; this prescription totals 2,400 mg/day, creating a high risk for toxicity and serious adverse effects (e.g., CNS depression, ataxia, hyponatremia, and hematologic complications). Teaching about warning signs or giving with meals are appropriate only after the dose is verified to be within safe limits. Questioning the order best addresses the immediate risk and is the priority first action.

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