Question 1

Which of the following is an example of whistleblowing?

Accepted Answer

Answer reason: Whistleblowing involves reporting unethical or illegal behavior within an organization to an authority. Reporting a colleague’s misuse of supplies to administration is an example of professional accountability and ethical responsibility.

Question 2

A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurologic impairment. Legally, who is responsible for the child's injury?

Accepted Answer

Answer reason: A toddler with a high fever and a known history of febrile seizures has a foreseeable risk for seizure-related harm, so additional nursing actions (reassessment, escalation up the chain of command, and timely documentation) are expected when the initial response is non-intervention. Simply accepting the provider’s decision does not remove the nurse’s accountability for failure to intervene when risk is evident. The provider may share responsibility, but the question’s key lapse is the nurse’s failure to pursue further action despite concern, which directly contributed to preventable risk.

Question 3

A patient is refusing their medication. The nurse pushes them to the ground in order to administer the IM medication, and in so doing causes the patient to strike their head and lose consciousness. Which tort has the nurse committed?

Accepted Answer

Answer reason: The client clearly refused the medication, so physically forcing the client to the ground to give an IM injection constitutes nonconsensual contact. The resulting injury (head strike and loss of consciousness) is not required to prove battery, but it strengthens the harm element and underscores the seriousness of the tort. By contrast, assault is the threat or attempt to cause harmful/offensive contact without necessarily making contact, whereas here contact and force clearly occurred. Malpractice/negligence focus on breach of a professional duty of care; the primary issue in this scenario is intentional, unconsented physical contact.

Question 4

A nurse fills out an incident report after a client fall. The charge nurse instructs the nurse to "just fix it in the chart and skip the report." What is the nurse’s best action?

Accepted Answer

Answer reason: Nurses have a legal and professional duty to document and report safety events accurately to support patient safety and organizational risk management. Completing the incident report per policy ensures the fall is properly evaluated, tracked, and addressed through quality improvement processes. Altering charting to conceal details is unethical, can constitute falsification of the medical record, and increases liability risk. Even if no injury is apparent, falls require reporting because harm may be delayed and system issues (environment, staffing, equipment) must be identified and corrected.

Question 5

AATB standards require that tissue banking maintain SOPs encompassing all of the following except?

Accepted Answer

Answer reason: Standard operating procedures (SOPs) are internal, facility-specific protocols. While they must align with regulatory requirements, FDA regulations themselves are external governing rules and are not considered part of SOP content. The other options describe internal processes that must be included in SOPs.

Question 6

Situation: – As Filipino Professional Nurses we must be knowledgeable, about the Code of Ethics for Filipino Nurses and practice these by heart. The next questions pertain to this Code of Ethics. A nurse should be cognizant that professional programs for specialty certification by the Board of Nursing are accredited through the?

Accepted Answer

Answer reason: The body intended for this role is the specialty-certification accrediting council aligned with the Board of Nursing’s framework for recognizing specialty credentials. The PRC primarily focuses on licensure and overall professional regulation rather than accrediting specialty certification programs. Professional associations (e.g., PNA) and academic dean associations support the profession and education but are not the designated accrediting authority for BON specialty certification programs.

Question 7

Jeremiah, a clinical instructor, is discussing the list of controlled substances schedules. The following are considered to be under Schedule I controlled substances, except?

Accepted Answer

Answer reason: Schedule I substances have no accepted medical use in the U.S. and a high potential for abuse (e.g., cannabis and LSD are commonly tested examples). Oxycodone is an opioid analgesic with accepted medical use for pain management and is therefore placed in a lower schedule (commonly Schedule II) rather than Schedule I. Recognizing these distinctions supports safe, legally compliant medication handling and patient education.

Question 8

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), Dr. Smith orders diagnostic tests of the vaginal discharge. Which STD must be reported to the public health department?

Accepted Answer

Answer reason: Gonorrhea is a nationally notifiable STI in most jurisdictions, so confirmed or suspected cases must be reported to the local/state health department. This allows timely contact tracing and treatment of partners to reduce reinfection and community spread. In contrast, conditions like genital herpes and HPV are commonly managed clinically but are not routinely reportable in many reporting systems.

Question 9

The nurse working in a long term care facility is orientating a new nurse to the facility. The nurse should tell the new nurse that which of the following is the priority reason that health care issues of older adults become an ethical dilemma?

Accepted Answer

Answer reason: This option directly captures that tension: the client’s legal rights (e.g., informed consent/refusal, advance directives) can clash with the nurse’s duty to provide care and prevent harm. The other options describe contributing features of decision-making (values, ambiguity, time pressure) but do not define the central ethical conflict that drives many long-term-care dilemmas. When rights and professional obligations collide, nurses must use ethical frameworks and legal standards to guide action while protecting the client’s dignity and self-determination.

Question 10

A nurse is teaching a group of older adult clients about advance directives. Which of the following statements by a client indicates a need for further teaching?

Accepted Answer

Answer reason: " Advance directives should be reviewed and updated whenever a person’s health status, goals of care, or preferences change, and after major life events (e.g., new diagnosis, hospitalization, changes in family/support). Limiting updates only to interstate moves reflects misunderstanding because the need to revise is driven by changes in wishes and clinical circumstances, not geography alone. While state-specific forms and witnessing requirements can differ, many directives are still honored across states, and updating is not restricted to relocation. The other statements correctly describe the purpose of a durable power of attorney for health care, a living will, and that both can coexist.

Question 11

Nurse Megan reviews a physician's order and considers her obligation to follow it. Under what circumstance is she obligated to question or refuse to carry out the order?

Accepted Answer

Answer reason: Nurses are legally and ethically accountable to protect the client and must not implement an order that is unsafe or outside policy/standards. An order that appears incorrect, contraindicated, or likely to cause harm requires the nurse to clarify with the prescriber and follow the chain of command if needed. This aligns with the duty to advocate and prevent negligent acts, even when the order originates from a provider. In contrast, issues like transcription status or the fact that an order was verbal do not automatically make it unsafe; they require proper documentation/verification, but not refusal unless safety/policy concerns exist.

Question 12

Treatment of a patient without consent can constitute _____ which is defined as intentional and unwanted touching?

Accepted Answer

Answer reason: Providing treatment without valid consent meets this definition because the act involves physical contact that the patient did not authorize. In contrast, negligence is unintentional and centers on a breach of duty causing harm rather than deliberate contact. Slander is a defamation claim involving spoken statements, not physical contact. Therefore, the scenario most directly fits the intentional, unwanted touching standard.

Question 13

Bioethical issue should be describe as_____?

Accepted Answer

Answer reason: Advance directives are a core bioethical and legal mechanism for preserving patient autonomy when decision-making capacity is lost. A written directive created while competent provides ethically valid guidance for withholding or withdrawing interventions, including artificial nutrition and hydration, when the patient can no longer speak for themselves. This scenario directly tests the ethical principle of respect for autonomy and the related legal right to refuse treatment. In contrast, unilateral physician decision-making violates autonomy, and research designs that treat groups differently raise justice/ethical research concerns rather than end-of-life directives.

Question 14

When a nurse in-charge causes an injury to a female patient and the injury cause negligent and the presence of the injury is said to exemplify the principle of _______?

Accepted Answer

Answer reason: In such cases, the existence of the injury can be sufficient to infer negligence even without direct proof of the exact act that caused it, shifting the burden toward the defendant to rebut. This fits a patient injury described as negligent by its very occurrence. A common distractor is vicarious liability, which focuses on an employer’s responsibility for an employee’s acts rather than the evidentiary inference drawn from the nature of the injury.

Question 15

Nurse Myma is aware that the Board of Nursing has quasi-judicial power. An example of this power is?

Accepted Answer

Answer reason: Investigating alleged violations of nursing laws and ethical standards is a core function that supports due process and protects the public through enforcement actions. By contrast, issuing rules and regulations is a quasi-legislative function, not quasi-judicial. Preparing board examinations is an administrative/regulatory task rather than an investigative or adjudicative function.

Question 16

When the license of nurse Kriea is revoked, it means that she?

Accepted Answer

Answer reason: Revocation is a formal disciplinary action that withdraws the authority to practice, but it does not always mean a permanent, irreversible ban. Nursing regulation commonly allows a revoked license to be reconsidered for reissuance after a defined period or upon meeting specific legal and administrative conditions (e.g., rehabilitation, compliance with penalties, fulfillment of requirements). This option directly reflects that revocation can still have a pathway to reinstatement when the governing law provides for it. Options implying an absolute lifetime prohibition are overly definitive and not universally accurate across professional regulatory frameworks. The key concept tested is the legal status and potential remedies available after a regulatory sanction.

Question 17

A 78-year-old woman is brought to the emergency department (ED) for evaluation of an arm injury. During the assessment, the nurse notices bruises in varying stages of healing covering the client’s chest and legs. When the nurse asks how the bruises were sustained, the client reluctantly states that her son frequently hits her “if supper is not ready when he gets home from work.” Which of the following is the most appropriate nursing response?

Accepted Answer

Answer reason: Elder abuse is suspected when there are injuries in various stages of healing and a disclosure of being hit, and the nurse must respond with safety-focused, legally appropriate action. The priority is to protect the client and follow mandatory reporting laws and facility policy rather than confronting the alleged abuser or suggesting the client “manage” the abuser’s behavior. Informing the client about mandated reporting is transparent and supports trust while initiating protective interventions. Options that contact the son directly or imply the client is responsible for preventing the violence are unsafe and inappropriate, and suggesting informal safety plans alone does not fulfill the nurse’s legal duty to report.

Question 18

A nurse fails to give a scheduled medication in a timely manner and the patient suffers injury. The nurse is most likely to be guilty of which legal infraction?

Accepted Answer

Answer reason: Failing to administer a scheduled medication on time represents a deviation from the standard of care, and the stated patient injury establishes damages linked to that deviation. When negligence is committed by a licensed professional in the course of professional duties, it is termed malpractice. Libel involves written defamation, which is unrelated to medication administration errors.

Question 19

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?

Accepted Answer

Answer reason: This entry describes a concrete physical finding that can be validated and trended over time, making it a legally sound and clinically useful note. By contrast, “appears to be sleeping” is an inference; a more objective description would focus on observable behaviors (e.g., eyes closed, regular respirations, responds to name). “Medication provided” lacks required details (drug, dose, route, time, and response), and “Voided x 1” is incomplete without amount/characteristics and often time.

Question 20

A 3-month-old infant is treated in the emergency department (ED) for a fractured femur. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?

Accepted Answer

Answer reason: Prompt, detailed documentation of the injury characteristics and the stated mechanism preserves the medical-legal record and supports timely interdisciplinary evaluation and mandatory reporting processes. Questioning the parent can be appropriate, but it is not the first priority compared with establishing objective findings and the exact reported timeline/mechanism in the chart. Reporting concerns is ultimately required, but it should be based on clearly documented observations rather than speculation, and photographing injuries is typically provider/agency-directed with consent and policy.

Question 21

The LPN/LVN is caring for a client who states, “I just want to die.” The LPN/LVN should examine the client’s medical record for which of the following documents?

Accepted Answer

Answer reason: This umbrella documentation includes the client’s preferences for treatments and decision-making (e.g., living will and designation of a surrogate decision maker), which directly informs how the team should proceed. A DNR is a specific medical order about resuscitation only and may or may not exist even when broader goals-of-care documents are present. Power of attorney alone may not address treatment preferences, so reviewing the broader directives best supports legally and ethically appropriate care planning while further assessing for suicidality.

Question 22

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take?

Accepted Answer

Answer reason: A 10 mg IV push hydromorphone order is markedly higher than the usual PRN dose range and carries high risk of respiratory depression, hypotension, and oversedation, especially post-operatively. The safest initial action is to contact the prescriber to question/clarify the order (e.g., possible decimal error or intended different opioid/route) and obtain a corrected prescription. Administering first is unsafe, and consulting colleagues or checking prior dosing may provide context but does not resolve the immediate unsafe order that requires prescriber clarification.

Question 23

An elderly patient is in cardiac arrest and a family member presents a do not resuscitate (DNR) order. Which of the following is a common requirement in order for a DNR to be valid?

Accepted Answer

Answer reason: Having the patient’s medical problems documented is a common element that supports identification and clinical applicability of the order in emergent situations. A list of allergies and medications may be important for treatment decisions but they are not typically defining validity elements of a DNR order itself. A narrative of events leading to arrest is not required for the legal/clinical validity of a DNR.

Question 24

If a nurse applies a restraint vest without the patient's permission or a physician's order, the nurse may be charged with?

Accepted Answer

Answer reason: Applying a restraint vest without a provider order (when required by policy/law) and without the patient’s consent constitutes unpermitted physical contact, meeting the definition of battery. Assault is the threat or act that creates fear of imminent harm without necessarily touching; the restraint application involves actual contact. Neglect refers to failure to provide needed care, and invasion of privacy concerns confidentiality or exposure rather than physical restraint.

Question 25

During the assessment of a child, the nurse notes that the child's genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance?

Accepted Answer

Answer reason: Suspected child sexual abuse triggers mandatory reporting requirements, and the nurse’s priority is to initiate the legal protection process so the child can be safeguarded and investigated appropriately. Reporting ensures timely involvement of child protective services/law enforcement and helps prevent ongoing harm. Documentation is important for an accurate record, but it does not replace the immediate duty to report when abuse is suspected. Referrals and resource support are appropriate after immediate safety and reporting obligations are addressed.

Question 26

A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: The key principle is that advance directives must be executed according to state law and facility policy to avoid conflicts of interest and ensure validity. Nurses commonly have restrictions from serving as witnesses for a patient’s living will/advance directive, so the safest response is to decline and follow the proper process for obtaining an eligible witness. Suggesting the physician as a witness does not resolve the same potential legal/policy limitations and may still be inappropriate. Family members are not the only possible witnesses, and an attorney is not typically required to be present for a living will to be signed.

Question 27

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering?

Accepted Answer

Answer reason: Using an antipsychotic solely to stop a patient from getting out of bed addresses a safety management issue with sedation rather than treating an appropriate medical/psychiatric indication, creating legal and ethical risk. In contrast, benzodiazepines are an expected first-line treatment for severe alcohol withdrawal agitation, and antipsychotics may be used when violent behavior poses an immediate safety threat as part of behavioral emergency management. Sedation with propofol in an intubated, mechanically ventilated patient is a standard ICU practice with appropriate monitoring and protocols.

Question 28

A client in the medical ward is adamant to go home regardless of what the medical team is telling him. The nurse understands that in order for all healthcare team members to be protected from liability when the client goes home, the nurse must first initiate which action?

Accepted Answer

Answer reason: A client’s right to refuse treatment and leave depends on having decision-making capacity, which must be evaluated before any legal documentation is meaningful. A focused mental and neurologic assessment helps determine orientation, cognition, and presence of impairment (e.g., delirium, intoxication, hypoxia) that could invalidate refusal and trigger safety measures or further provider evaluation. If capacity is intact, the team can then proceed with informed refusal counseling and appropriate documentation, reducing liability risk. Relying first on an AMA form is insufficient if capacity is questionable because a signature does not establish that the refusal was informed and competent.

Question 29

What should a nurse do if, at the end of a shift, he/she realizes that he/she forgot to document a dressing change performed for a patient?

Accepted Answer

Answer reason: Documentation must be accurate, timely, and truthful; when something is omitted, the correct legal and professional response is to add a properly identified late entry. A late entry preserves the integrity of the record by clearly indicating it is being entered after the fact with the correct date/time and factual details of the care provided. Backdating or inserting the information into an earlier note is falsification and can create legal risk and patient-safety issues. An occurrence report is used for unusual events/incidents, not routine late charting, and relying on the next nurse undermines continuity and accountability.

Question 30

The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6 L/min. Results show pH 7.37, HCO3 26 mm Hg, pCO2 42 mm Hg, pO2 90 mm Hg. Which of the following should the nurse do FIRST?

Accepted Answer

Answer reason: ABG values shown are essentially within normal limits, indicating adequate ventilation and oxygenation on the current therapy. With no evidence of hypoxemia or acid–base disturbance, there is no immediate need to escalate oxygen, reposition, or initiate airway clearance solely based on these numbers. The appropriate first action is to record and communicate objective findings as part of safe, legally accountable care. Changing oxygen flow without an indication could create unnecessary risk (e.g., in CO2 retainers) and is not supported by the data provided.

Question 31

An older adult client falls and fractures her hip while the nurse is assisting her to the bathroom. The client sues the nurse for negligence. In the legal proceedings, which of the following standards should be used to determine if the nurse is liable for the client's injury?

Accepted Answer

Answer reason: Negligence is judged against the professional standard of care, meaning what a reasonably prudent nurse would do in similar circumstances. Testimony describing typical nursing practice under the same conditions helps the court decide whether the nurse’s actions met that standard. Statements from an attorney are advocacy, not evidence of the nursing standard of care. Provider opinions or vague claims that things could be done differently may be informative but do not define the nursing standard used to establish breach.

Question 32

Who should write the report of a patient having a fall in the bathroom?

Accepted Answer

Answer reason: A witness can document objective details such as what occurred, the time, circumstances, immediate assessment findings, and actions taken without relying on secondhand information. The RN in charge may coordinate assessment, notifications, and follow-up care, but should not author a report based on information reported by others. Family members are not part of the facility’s clinical documentation system and cannot meet institutional/legal requirements for an internal incident report.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Legal Rights-Responsibilities Practice Test 5

Legal Rights-Responsibilities NCLEX Practice Test

Continue Learning