Question 1

The client’s son asks the hospice nurse to administer larger doses of pain medication. Despite having pain, the client, who is Hispanic, adamantly refuses increased doses. The client states, "I believe that accepting pain is God's will for me." By withholding larger analgesic doses, the nurse best demonstrates ethical practice guided by which principle?

Accepted Answer

Answer reason: The son’s request does not override the client’s stated preference, even in hospice where comfort is a priority. Honoring the client’s religiously informed refusal reflects respect for self-determination and prevents unwanted treatment. Beneficence would support pain relief, but it cannot supersede a capable client’s refusal when choices conflict.

Question 2

Which circumstance would keep the nurse from being liable for professional negligence when the nurse made an error when administering a drug?

Accepted Answer

Answer reason: Negligence/malpractice requires actual damages (patient harm) in addition to duty, breach, and causation. If an error occurred but resulted in no injury, the element of damages is not met, so professional negligence is not established even though the error should still be reported and addressed. Not knowing a contraindication reflects a failure to meet the standard of care and does not protect from liability if harm occurs. Reliance on a coworker or pharmacy does not remove the nurse’s independent responsibility to verify medication safety before administration.

Question 3

A client was voluntarily admitted to the inpatient psychiatric admission for anxiety. He is alert, oriented, and denies suicidal ideation. He states that he wants to leave. The most appropriate action by the nurse would be?

Accepted Answer

Answer reason: A voluntarily admitted, competent client generally retains the legal right to request discharge, so the nurse must follow facility policy and provider orders rather than unilaterally detaining the client. Notifying the attending provider initiates the proper legal process (e.g., evaluation of decision-making capacity and safety risk, and whether criteria exist for an involuntary hold). Telling the client they cannot leave AMA is inaccurate and can violate client rights. Providing discharge instructions is premature until the provider evaluates the situation and the discharge/AMA process is formally initiated and documented.

Question 4

The unresponsive client is unable to give consent for surgery. The client has an advance health care directive that identifies a friend as the legal health care agent. Who should the nurse contact for obtaining consent for this client?

Accepted Answer

Answer reason: An advance directive that names a health care agent (durable power of attorney for health care) designates that person as the priority decision-maker over next of kin. Therefore, the nurse should contact the named agent to provide consent consistent with the client’s wishes and best interests. The spouse or adult child would only be approached if no legally appointed agent existed or if the agent were unavailable per facility policy and state law. Non-emergent surgery can proceed with surrogate consent; only emergent, life-saving care may proceed without consent under implied consent.

Question 5

When a nurse accepts a client assignment, the nurse also accepts a legal duty to provide care to the client that is consistent with the standard of care. A nurse who abandons a client assignment without first procuring comparable and appropriate care for the client during the period of the nurse’s absence is guilty of (choose the best answer)?

Accepted Answer

Answer reason: Negligence analysis starts with the existence of a duty, then evaluates whether the clinician’s actions fell below the accepted standard of care. Abandoning an accepted assignment without arranging appropriate coverage violates the obligation to provide continuous, safe care and therefore represents a failure to meet the standard. The other elements (damages and causation) require proof of patient harm and a direct link between the act and the harm, which are not required to label the conduct described in the stem. The scenario specifically describes the nurse failing to uphold the required duty, which is the defining feature of this element.

Question 6

The registered nurse is caring for a neonate diagnosed with a cardiac anomaly. The pediatrician orders digoxin (Lanoxin), 2.5 mg. The nurse questions the order with both the pharmacist and physician. The nurse demonstrates responsible professional practice according to which of the following?

Accepted Answer

Answer reason: Questioning an unusually high medication dose for a neonate and clarifying it with the pharmacist and prescriber reflects the nurse’s duty to ensure safe care before administration. This accountability and obligation to intervene when an order appears incorrect are grounded in state nursing law and regulation. Professional association guidelines inform practice, but the enforceable legal standard for RN responsibilities and scope is established by the Nurse Practice Act.

Question 7

The nurse is reviewing the HCP orders for the newly admitted child with second- and third-degree burns over 10% of the total body surface area (TBSA). The child weighs 20 kg. Which order should the nurse clarify?

Accepted Answer

Answer reason: Medication orders must be clear, complete, and unambiguous to prevent administration errors. The abbreviation/wording "IV pm" is not a standard, precise dosing instruction and could be misinterpreted (e.g., timing vs route vs frequency), creating a high risk for incorrect administration. In acute burn care, opioid analgesia is appropriate, but the order should specify an exact dose, route, and dosing interval (and any parameters), so it requires clarification before giving. The other orders reflect common burn management actions (fluid resuscitation/monitoring and edema control) and are not inherently unclear.

Question 8

During resuscitation efforts of a trauma victim, the spouse tells the nurse that her husband has terminal cancer, has completed an advance I-ICD, and does not want CPR. What should be the nurse’s next action?

Accepted Answer

Answer reason: In a resuscitation, CPR continues unless there is a valid, verifiable order or directive (e.g., DNR/POLST) that can be confirmed and is applicable to the current situation. A spouse’s verbal report alone is not sufficient legal authority to terminate CPR without confirmation of the document or provider order. The fastest appropriate step is to verify whether the health care directive is on file (or otherwise immediately available) so the team can act in accordance with legally enforceable wishes. Simply stopping efforts risks wrongful death and liability, while documentation and notifying the provider are important but do not replace immediate verification needed to guide the code.

Question 9

A male client with a terminal illness is unconscious. His wife wants him to be a full code; his sister who has papers as durable power of attorney for health care says to make him a “DNR” (do not resuscitate). How should the situation be handled legally?

Accepted Answer

Answer reason: When a patient lacks decision-making capacity, the legally designated surrogate decision-maker has authority to make healthcare decisions within the scope of the advance directive/POA. A durable power of attorney for health care generally overrides other family members’ preferences, even a spouse, unless there is a valid court order or evidence the document is invalid. Code status decisions (including DNR) are medical orders that should align with the authorized surrogate’s direction and the patient’s known wishes/values. Ethics or chaplain support can be helpful for conflict and coping, but they do not replace the legal hierarchy for consent and decision-making.

Question 10

Which action can the nurse be legally liable for?

Accepted Answer

Answer reason: Giving a cephalosporin to a patient with a documented penicillin allergy can be negligent because of potential cross-reactivity and the risk of a serious hypersensitivity reaction, especially if the allergy history suggests anaphylaxis. In contrast, giving 2 mg hydromorphone is within the ordered dose range, and holding digoxin for bradycardia or holding a nitrate with profound hypotension reflects appropriate clinical judgment and standard safety parameters. Administering a potentially contraindicated antibiotic despite a known allergy is the action most likely to create avoidable injury and legal liability.

Question 11

The client has been placed in involuntary seclusion. Which assessment observation best indicates to the nurse the client's readiness to leave involuntary seclusion?

Accepted Answer

Answer reason:  Readiness for release from seclusion is best demonstrated by behavioral and emotional self-control with de-escalation, not by time elapsed or charted impressions. A calm, verbalized ability to control anger reflects improved impulse control and reduced immediate risk of harm to self/others, which is the key criterion for ending seclusion. Normal vital signs do not assess aggression risk and can be normal even when a client remains threatening. Sitting in the doorway and requesting a drink shows some cooperation but does not directly establish regained control of potentially violent behavior, and documentation alone is not a current assessment finding.

Question 12

The nurse is caring for the client who is angry about a new diagnosis of gonorrhea. The client informs the nurse, “I absolutely will not allow the release of this information to anyone.” Which response by the nurse is most appropriate?

Accepted Answer

Answer reason:  Public health law requires reporting certain communicable diseases, including many sexually transmitted infections, to the local/state health department for surveillance and partner notification efforts. The nurse’s priority is to provide accurate information about legal limits of confidentiality and what must be disclosed versus what remains private. This response is direct, truthful, and sets appropriate expectations while still allowing for supportive follow-up discussion. The other options either deflect from the legal requirement, make assumptions about the client’s concerns, or minimize the client’s emotions, which can escalate conflict and does not address mandatory reporting.

Question 13

A client with a femoral fracture is in skeletal traction. During the initial shift assessment, the nurse finds that the weight used in traction is heavier than specified by the nursing care plan. Which action should the nurse take first?

Accepted Answer

Answer reason: The core principle is to verify current, authorized prescriptions before changing a therapy that can cause harm. Skeletal traction weight is a provider-prescribed parameter; an unexpected increase could be intentional or could represent an error, so the nurse should first confirm the most recent order in the chart. This step prevents both continuing a potentially unsafe setup and inappropriately altering a treatment that was legitimately changed. Immediately changing the weight without verifying orders can compromise alignment/traction effectiveness and creates legal and safety risk.

Question 14

When examining a nursery school-age child, the nurse finds multiple contusions over the body. Child abuse is suspected. Which statement indicates which findings should be documented?

Accepted Answer

Answer reason: Accurate, objective, and detailed documentation is a legal and clinical requirement when abuse is suspected and may become evidence in investigations. Recording location, size/shape/pattern, and color of each lesion supports assessment of injury mechanism and timing while avoiding speculative interpretations. This approach also establishes a baseline for follow-up exams and supports multidisciplinary reporting processes. By contrast, relying on generalizations about what is “typically suspicious” or simplistic pattern rules can be inaccurate and does not meet documentation standards. Comprehensive descriptive charting (often supplemented by body maps/photographs per policy) best protects the child and supports mandated reporting.

Question 15

Entering a client’s room to get a neonate for an examination by the physician, the nurse on the maternity unit sees the client holding the crying neonate and slapping his face. Which action is most appropriate?

Accepted Answer

Answer reason: The immediate priority is the neonate’s safety, so separating the infant from potential ongoing harm is essential. Suspected child abuse requires prompt assessment for injury and timely reporting through appropriate channels; informing the provider supports medical evaluation and documentation. Notifying social services initiates mandated protective interventions and follow-up, which is a legal and ethical nursing responsibility. Options that delay protection (leaving the infant in the room) or rely on informal observation do not meet mandatory reporting and immediate safety requirements.

Question 16

The client with end-stage cardiomyopathy states, “I do not want to be resuscitated if I stop breathing.” Full resuscitation is noted on the client’s medical record under code status. Based on this information, which action should the nurse take first?

Accepted Answer

Answer reason: The immediate safety issue is that the chart indicates full code, so without rapid escalation the client may receive unwanted CPR during an arrest. Documentation of the statement is appropriate but does not change orders and should not delay notifying the provider to reconcile the discrepancy. Involving a surrogate is not the first step when the client is expressing their own wishes and appears able to communicate them.

Question 17

The nurse makes an error by documenting the wrong VS in the client’s written medical record. Which action would be best to correct the error?

Accepted Answer

Answer reason: Medical record corrections must preserve the original entry’s visibility and create a clear, auditable trail that shows what was changed, when, and by whom. A single line through the incorrect data with date/initials maintains record integrity while preventing any appearance of concealment or falsification. The corrected information should be documented as a new, accurate entry to ensure continuity of care and legal defensibility. Techniques like highlighting, circling, or overwriting can obscure the original information or be interpreted as altering the record improperly.

Question 18

The male client diagnosed with a brain tumor who is receiving hospice care is admitted to the hospital and provides the nurse with a copy of his living will, stating he does not want any heroic measures. Which action should the nurse implement first?

Accepted Answer

Answer reason: A living will expresses the client’s preferences, but resuscitation decisions in the hospital must be translated into an active, provider-entered code-status order to be actionable during an emergency. Verifying the presence of a DNR order is the most time-critical step to prevent initiation of unwanted CPR or other resuscitative “heroic measures.” Notifying the provider and filing the document are important, but they do not immediately ensure staff will follow the client’s wishes if the client deteriorates suddenly. Spiritual support can be offered as appropriate, but it does not address the immediate legal/clinical mechanism that guides emergency interventions.

Question 19

The nurse establishes a nurse–client relationship and a duty to the client upon accepting the client care assignment. What is the correct definition of "breach of duty?"

Accepted Answer

Answer reason: Breach of duty is the element of negligence in which a nurse does not meet the expected standard of care (an act or an omission). Once a duty is established by accepting the assignment, the question becomes whether the nurse’s conduct fell below professional standards. The other options describe different negligence elements: duty (A), damages (C), and causation/proximate cause (D). Therefore the definition that matches breach of duty is failure to provide care consistent with standards.

Question 20

A registered nurse (RN) is supervising the care of a licensed practical nurse (LPN). The LPN is voicing concerns about a terminal client’s end-of-life plan. Which statement by the LPN would indicate to the RN that further teaching is needed?

Accepted Answer

Answer reason:  Advance directives are legal documents that remain valid across care settings unless revoked or replaced by the client according to state law. A new hospitalization does not automatically require creating a new living will; instead, the existing document should be reviewed and placed in the medical record. The other statements describe accurate end-of-life planning concepts: living wills outline preferences, a durable power of attorney can designate a surrogate decision-maker, and a DNR order communicates refusal of CPR. This incorrect legal claim could lead to unnecessary confusion and delay in honoring the client’s expressed wishes.

Question 21

When making rounds after returning from lunch, the nurse assesses a client's pain as 9 out of 10 on a 0 to 10 pain scale. There is no record of an opioid being given to the client, even though the previous nurse signed for one at 12:15 p.m. The client denies receiving anything for pain since the previous night. Which action should the nurse take next?

Accepted Answer

Answer reason: Narcotic discrepancies require immediate, stepwise follow-up using the chain of accountability and medication security procedures. The most appropriate next step is to directly clarify with the nurse who removed/signed for the medication, because the dose may have been administered but not documented, wasted with a witness, returned, or charted on a different record. This action is timely, nonaccusatory, and often resolves documentation errors quickly while protecting patient safety and controlled-substance integrity. If the discrepancy cannot be reconciled promptly, then escalation to the charge nurse/supervisor and formal controlled-substance discrepancy procedures would follow.

Question 22

As the nurse prepares to administer prophylactic eye treatment to prevent gonorrhea conjunctivitis in the full-term newborn, the newborn’s father asks if it is really necessary to put something into his baby’s eyes. Which statement should be the basis for the nurse’s response?

Accepted Answer

Answer reason: Neonatal ocular prophylaxis is a mandated public health measure intended to prevent ophthalmia neonatorum, which can rapidly lead to corneal damage and blindness if caused by gonococcal infection. The nurse’s response should be grounded in the legal requirement for routine newborn prophylaxis rather than presenting it as optional. A verbal parental request alone is not the appropriate basis to omit a legally required newborn intervention; refusal, if allowed by local policy, typically requires formal informed refusal processes. Oral antibiotics are not an equivalent substitute for immediate ocular prophylaxis, and the intervention is time-sensitive in the immediate newborn period rather than deferrable for months.

Question 23

The infant with burn injuries caused by the ingestion of a strong alkali is intubated and has been sedated. The parents, who have limited English, ask through an interpreter what will happen to their baby. Based on the protocol for this emergency situation, which intervention is most important for the nurse to address with the parents?

Accepted Answer

Answer reason: In suspected nonaccidental injury or neglect, clinicians are mandated reporters and must initiate protective services involvement per protocol while continuing emergent stabilization. A caustic alkali ingestion in an infant is a high-risk sentinel event because the child is developmentally unable to access such substances independently, so safety assessment and safeguarding are immediate priorities. This action is time-sensitive, nonoptional, and should be communicated clearly to caregivers using an interpreter to ensure understanding and reduce confusion. Diagnostic studies and potential long-term complications are important but occur after or alongside mandatory safety/legal steps and do not supersede reporting requirements.

Question 24

The client is being admitted to the ICU with drug overdose that resulted in extreme hypertension and an unstable cardiac rhythm. The client suddenly becomes physically combative and is kicking, shoving, throwing items in the room, and threatening staff. The charge nurse calls a behavioral situation code, and 4-point restraints are applied by the team. Which intervention is most important for the nurse to implement next?

Accepted Answer

Answer reason: After emergency restraints are applied to manage imminent danger, the nurse must obtain a provider order within the required time frame to ensure the intervention is legally authorized and meets regulatory standards. This step also prompts immediate medical evaluation of the need for restraints and establishes required parameters (type, reason, duration, monitoring). Documentation and incident reports are important but are secondary to securing the order that governs ongoing restraint use. Ensuring restraints are not overly tight and are secured properly is part of safe application, but “tightly secured” is unsafe and does not address the priority legal requirement once restraints are in place.

Question 25

The 19-year-old is given a court order to enter treatment for cocaine abuse. The client threatens to leave the treatment facility AMA. Which statement by the nurse demonstrates an accurate understanding of the client’s options?

Accepted Answer

Answer reason:  A court-ordered treatment admission is not purely voluntary, so the client does not have the same freedom to leave AMA as in a standard elective admission. If the client attempts to leave, the appropriate response is that leaving triggers legal consequences and the court can mandate return to treatment or impose an alternative disposition. Seclusion is a behavioral emergency intervention requiring clinical justification and is not an automatic legal response to noncompliance. Informing the court and “preparing documents” does not convert the situation into a permissible AMA discharge because the order governs the client’s options.

Question 26

The nurse notes that a hospital coworker omits treatments for clients, has mood swings, makes frequent requests for help with assignments, and has numerous requests to witness the waste ofcontrolled substances. Which nursing action is most appropriate?

Accepted Answer

Answer reason: The behaviors described (omitted care, mood swings, frequent help requests, repeated controlled-substance waste witnessing) are classic diversion/impairment red flags that put patients at risk. Confronting the coworker directly can be unsafe, may provoke denial or retaliation, and does not ensure timely protection of patients. Calling police is not the first step in most institutions; internal reporting and risk management/employee health processes are the appropriate initial pathway.

Question 27

The RN is discharged for jeopardizing client safety by consistently failing to notify the HCP of changes in clients’ health status. Which statement by the nurse manager is most appropriate when another health care facility telephones for a reference check on the RN?

Accepted Answer

Answer reason:  The key principle is to provide employment references that are objective, factual, and limited to what can be verified to reduce risk of defamation and protect confidentiality. This statement shares neutral, documentable facts (unit and dates/tenure with discharge status) without alleging performance problems or motives. Disclosing specific safety failures or subjective characterizations invites legal exposure and may exceed what the organization’s policy permits. When in doubt, managers should follow institutional reference policy, but the safest appropriate content in a reference is minimal verified employment information.

Question 28

The experienced nurse is orienting the new nurse to essential documentation when caring for clients through a home health care agency. Which statement should be made by the experienced nurse regarding home health documentation?

Accepted Answer

Answer reason:  Home health documentation must establish medical necessity and skilled need to justify continued services and meet regulatory/payer requirements. Charting should clearly connect assessment findings to the need for skilled nursing interventions, teaching, or monitoring that cannot be safely performed by an unskilled caregiver. This focus is more essential than simply documenting “like the hospital,” because home care is episodic and reimbursement/authorization hinges on demonstrating skilled need. While payment is influenced by documentation quality, the primary principle is that documentation must support the need for skilled professional services rather than emphasizing reimbursement mechanics.

Question 29

The nurse manager learns that the LPN employed by the agency documented and signed the client’s EMR with the nurse’s name and credentials of LPN when the LPN was providing care as a student in an RN program. Based on this information, which action should be taken by the nurse manager?

Accepted Answer

Answer reason: Because the charting was entered under LPN credentials while functioning as an RN student, the situation involves scope/role accountability and requires immediate supervisory involvement from the school’s clinical instructor to ensure proper correction and education. Leaving the record “untouched” fails to address a known documentation error that could misrepresent who provided care and under what supervision. Deleting and reentering is generally inappropriate in EMRs because it can compromise the permanent record and tracking of amendments, increasing legal and regulatory risk.

Question 30

A nurse states to a nurse coworker, “The education coordinator and the charge nurse keep asking me for my new CPR and ACLS cards. I suppose that they will let me know when those certifications are about to expire.” What is the appropriate response by the nurse coworker regarding the nurse’s responsibility for continuing education?

Accepted Answer

Answer reason: Renewal of certifications required for employment and your nursing license are your responsibility as a nurse. You are fortunate that they care and that they reminded you that your certifications were due for renewal. Professional accountability is a core nursing legal/ethical duty, and maintaining required credentials is part of the nurse’s individual responsibility to practice safely and within employer and regulatory requirements. This response correctly redirects ownership to the nurse rather than placing the obligation on supervisors to track expirations. It also frames the reminders appropriately as supportive rather than as the primary control measure. Options that imply management will “keep” the list and repeatedly remind the nurse shift responsibility away from the licensee, and the dismissive comment undermines professionalism and safety culture.

Question 31

The nurse is preparing a client to receive ketamine to undergo a nerve block before being taken to the operating room for surgery on the left foot. Before the anesthesiology provider arrives to perform the nerve block, the nurse notices that the incorrect foot is listed as the operative site on the client’s signed informed consent form for the foot surgery. Which action by the nurse is correct?

Accepted Answer

Answer reason: A nerve block is an invasive, procedure-specific intervention tied to the operative site, so proceeding when the consent lists the wrong foot creates an immediate wrong-site risk. The nurse’s responsibility is to stop the process and ensure the discrepancy is corrected through the appropriate provider/patient verification rather than deferring the decision to anesthesia. Continuing with the block and “fixing it later” undermines legal validity of consent and patient safety safeguards such as site verification/time-out.

Question 32

The risk manager reviews an incident report completed by a nurse regarding a client's fall. Which finding in the report demonstrates inappropriate documentation?

Accepted Answer

Answer reason:  Incident reports should contain objective, factual, clinically relevant details about what happened, what the client reports, and the assessment findings and actions taken, while avoiding content that can create legal discovery issues or unnecessary identification of others. Listing witness names is generally inappropriate because it introduces additional personal information and shifts the report toward a legal statement rather than a quality/safety document. A proper report focuses on circumstances (environmental factors), the client’s statements, and observed injuries and interventions. Client statements and assessed injuries are appropriate because they directly support clinical evaluation, follow-up care, and risk reduction.

Question 33

The nurse is caring for a 7-year-old child who presents to the ED with multiple bruises, a fractured ankle, and cigarette burns on the arms. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: Escalating immediately through the charge nurse ensures timely activation of the reporting chain (e.g., child protective services/appropriate authorities) and safeguards the child. Directly accusing the parents is confrontational and can increase risk, shut down communication, or escalate violence. Detaining the family to wait for police is typically outside a nurse’s legal authority and may jeopardize safety; reporting through proper channels is the appropriate priority while continuing needed medical care and objective documentation.

Question 34

A nurse is caring for an elderly client in a long-term care facility. The client frequently presents with unexplained injuries, such as bruises and fractures. The nurse suspects elder abuse. What is the nurse's most appropriate action in this situation?

Accepted Answer

Answer reason: Nurses are mandated reporters and must act to protect vulnerable adults when abuse is suspected, not proven. Reporting through the facility’s established chain and to the proper external agencies triggers investigation and immediate safety interventions. Documentation is important but, by itself, delays protection and does not meet legal reporting duties. Directly confronting family members can escalate risk to the client and may compromise the integrity of an investigation.

Question 35

Nurse off from floor and patient fall from bed. This type of injury belongs to?

Accepted Answer

Answer reason: Leaving a patient in an unsafe situation that leads to a fall is a classic example of breach of duty with resulting damages. Battery involves intentional, nonconsensual touching and does not fit a fall event. The broader term “tort” is less specific than identifying the particular tort being tested here.

Question 36

The nurse is providing a staff training on nurses’ legal responsibilities to clients. Which of the following should the nurse provide as an example of malpractice?

Accepted Answer

Answer reason: Preventing pressure injuries in an immobile client (e.g., regular repositioning, skin assessment, pressure-relief measures) is a basic, well-established nursing standard. Omitting this care and the client subsequently developing a pressure injury demonstrates breach of duty with a clear causal link to harm. A common distractor is the coercive medication statement, which is inappropriate and may constitute assault/battery or false imprisonment, but it is not as directly framed as negligent care causing measurable injury.

Question 37

Malpractice is professional negligence that occurs when a nurse fails to meet the standard of care and causes client harm. The standard of care is the care that a reasonable and prudent nurse would provide in similar circumstances. Four criteria for malpractice must be met?

Accepted Answer

Answer reason: This element is what distinguishes a mere error or breach from actionable negligence, because harm must be shown to have occurred because of the nurse’s breach. Without causation, the other elements can be present (duty, breach, even injury), yet the injury could be attributable to an unrelated condition or unavoidable complication. Establishing causation typically depends on documentation and clinical timeline showing the breach directly led to the injury.

Question 38

The clinic nurse notices bruising at multiple stages of healing on a two-year-old. The nurse also sees two burns on the toddler's trunk. What would be the most appropriate action for the nurse to take?

Accepted Answer

Answer reason: Nurses are mandated reporters and must report reasonable suspicion of child abuse to the proper agency per law and facility policy. Bruising in multiple stages of healing plus burns on the trunk are red-flag injury patterns that warrant immediate reporting to protect the child. Confronting caregivers can escalate danger, jeopardize the child’s safety, and compromise subsequent investigation. Waiting to recheck delays safeguarding interventions and risks further harm. Notifying the HCP may occur, but it does not replace the nurse’s independent legal duty to report suspected abuse.

Question 39

A patient is yelling at the nurse, and the nurse states “if you don’t stop yelling at me, I’m going to tie you down.” Which tort has the nurse committed?

Accepted Answer

Answer reason: The nurse’s verbal threat to restrain the patient is a threat of unwanted physical contact, which can make the patient fear that harm is about to occur. Battery would require the nurse to actually apply restraints or touch the patient without consent. Malpractice and negligence involve breach of duty and failure to meet standards of care, not an intentional threat.

Question 40

A nurse cares for a client in the neonatal intensive care unit with respiratory distress syndrome. The nurse reviews the healthcare provider (HCP) prescriptions, noting an IV infusion at 400 mL/hr. Which action does the nurse take next?

Accepted Answer

Answer reason: Nurses must question and clarify provider orders that appear unsafe, especially in neonates where small errors can cause rapid, life-threatening fluid overload. An IV rate of 400 mL/hr is grossly excessive for a newborn and could precipitate pulmonary edema, worsening respiratory distress, and cardiovascular decompensation. The safest next step is to hold the infusion and obtain an immediate clarification/correction of the order before initiating therapy. Proceeding with the infusion or focusing on equipment checks does not address the potentially harmful prescription and delays prevention of an avoidable adverse event.

Question 41

A nurse accidentally administers the wrong dose of medication to a patient but the patient shows no adverse effects. What is the most ethical action the nurse should take?

Accepted Answer

Answer reason: Immediate provider notification allows assessment for delayed effects, need for monitoring, and any necessary interventions even when the patient is currently asymptomatic. Accurate documentation and completion of required reporting supports transparency, continuity of care, and quality improvement/systems analysis. Delaying or withholding reporting prioritizes self-protection over patient safety and violates standards of care and professional accountability.

Question 42

A confused patient repeatedly gets out of bed and wanders in the hallway. A nurse says to this patient, “If you do not stay in bed, I will restrain you.” What tort is this nurse committing?

Accepted Answer

Answer reason: Assault is the intentional act of making a person fear imminent harmful or offensive contact through threats or intimidation. The nurse’s statement is a threat of restraint that can reasonably cause the patient to fear being physically restrained, even though no contact has occurred yet. Battery would require the actual application of restraints or other unwanted touching. The other options do not fit because no private information is being intruded upon and no written defamation is involved.

Question 43

A patient states they wish to leave against medical advice and the nurse locks them in their room. Which type of tort has the nurse committed?

Accepted Answer

Answer reason: g., involuntary psychiatric hold). Confining a patient by locking them in a room is an intentional restraint of freedom of movement without legal justification. That meets the definition of false imprisonment, a type of intentional tort. Assault would involve threat of harm, battery would require unwanted physical touching, and negligence is unintentional breach of duty causing harm rather than deliberate confinement.

Question 44

A nurse causes harm to a patient by accidentally administering the wrong medication to a patient. What is the name of this tort?

Accepted Answer

Answer reason: Giving the wrong medication is a clinical duty that requires adherence to medication-administration standards (e.g., rights of medication administration), and harm from that error fits a breach-and-injury pattern. This is distinguished from assault or battery, which involve intentional threats or unauthorized touching rather than an unintentional medication error. While “negligence” is the broad concept, the specific term for negligence by a nurse in practice is professional negligence (malpractice).

Question 45

Which of the following situations is an example of negligence?

Accepted Answer

Answer reason: A dose of “2 oz” of cholestyramine is not a standard medication dose format and represents a high-risk transcription/communication error that should trigger clarification with the prescriber/pharmacy before processing. Proceeding to transcribe it as written can foreseeably cause patient harm, meeting the core elements of negligent practice. The other options describe appropriate care or infection-control behavior rather than a breach of duty.

Question 46

Active or positive euthanasia is a deliberate act to end a patient's life. which of the following is passive or negative euthanasia?

Accepted Answer

Answer reason: Withholding resuscitation measures such as CPR and oxygenation after arrest is an omission of intervention that would otherwise attempt to sustain life. In contrast, giving a substance or prescribing an agent intended to cause death represents an active step to end life. High-dose morphine may be ethically used for symptom relief under the principle of double effect when the intent is comfort, but the stem’s clearest passive example is non-initiation of resuscitation.

Question 47

A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?

Accepted Answer

Answer reason: Witnessing a living will is a legal process governed by state law and facility policy, and staff must avoid actions that could create a conflict of interest or invalidate the document. Escalating to the nursing supervisor ensures the nurse follows institutional procedures and that an appropriate, qualified witness is arranged. Simply offering to witness or assuming “whoever is present” can be inappropriate because witnesses may be restricted (e.g., involved in care, beneficiaries, or other disqualifying relationships). Telling the client to find a witness alone is not client-centered and fails to support safe, policy-compliant care.

Question 48

A nurse in the emergency department is assessing a child and notices bruises at different stages of healing. Which of the following actions should the nurse take next?

Accepted Answer

Answer reason: Objective, timely documentation of suspected abuse findings is a legal and professional duty and preserves the accuracy of the clinical record for subsequent medical and protective actions. Bruises in different stages of healing raise concern for non-accidental trauma, so the nurse should first record detailed, factual observations (location, size, color, shape, child’s statements in quotes) without speculation. While obtaining histories and notifying authorities are important, those steps are strengthened and defensible when supported by clear, contemporaneous documentation. This approach also supports continuity of care and helps ensure mandated reporting is based on accurately captured assessment data.

Question 49

The nurse administered an incorrect medication to a patient and decided to not complete an incident report since the patient was not harmed. Which ethical principle did the nurse violate?

Accepted Answer

Answer reason: Failing to file an incident report conceals a medication error and undermines accurate documentation, quality improvement, and systems-based prevention of future harm. Incident reporting is required even when no immediate injury is apparent because near-misses and no-harm events still represent patient safety risks. In contrast, beneficence focuses on doing good for the patient, but the key violation here is the lack of honesty and disclosure/accountability surrounding the error.

Question 50

A provider gives an order for non-violent restraints. How soon after this order must the provider perform an in-person assessment of the patient?

Accepted Answer

Answer reason: For non-violent/non-self-destructive restraints, the provider’s face-to-face assessment is required within 24 hours of initiating the order. This timeframe balances patient rights and safety with clinical practicality while ensuring ongoing justification and monitoring. Shorter intervals are associated with violent/self-destructive restraints, not routine non-violent restraint situations.

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Legal Rights-Responsibilities NCLEX Practice Test

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