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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank
Chapter 4
Question 1
Type: MCSA
Which of the following could result in the nurse being found negligent?
1. The nurse, while driving to work, passes the scene of an accident with obvious injury but does not stop.
2. The nurse administers the wrong medication to a client, who suffers no ill effect.
3. The nurse initiates a care plan to prevent skin breakdown and documents thoroughly, but the client develops a
pressure ulcer anyway.
4. The client with a history of dementia and wandering crawls over the side rail and falls, and breaks her hip.
Correct Answer: 4
Rationale 1: Answer option 4 is correct because the nurse should not have raised the side rails if the client has a
history of dementia and tends to wander, because it increases the risk of serious injury. The nurse in option 1
might have an ethical responsibility to act, but does not have a duty to the client involved in the accident, and so
cannot be found negligent. The nurse in option 2 created no harm, which must exist in order to find the nurse
negligent. The nurse in option 3 acted in the client's best interest. Pressure ulcers might not always be preventable
in clients who are severely malnourished or have very poor perfusion, so the client's harm was not the nurse's
fault.
Rationale 2: Answer option 4 is correct because the nurse should not have raised the side rails if the client has a
history of dementia and tends to wander, because it increases the risk of serious injury. The nurse in option 1
might have an ethical responsibility to act, but does not have a duty to the client involved in the accident, and so
cannot be found negligent. The nurse in option 2 created no harm, which must exist in order to find the nurse
negligent. The nurse in option 3 acted in the client's best interest. Pressure ulcers might not always be preventable
in clients who are severely malnourished or have very poor perfusion, so the client's harm was not the nurse's
fault.
Rationale 3: Answer option 4 is correct because the nurse should not have raised the side rails if the client has a
history of dementia and tends to wander, because it increases the risk of serious injury. The nurse in option 1
might have an ethical responsibility to act, but does not have a duty to the client involved in the accident, and so
cannot be found negligent. The nurse in option 2 created no harm, which must exist in order to find the nurse
negligent. The nurse in option 3 acted in the client's best interest. Pressure ulcers might not always be preventable
in clients who are severely malnourished or have very poor perfusion, so the client's harm was not the nurse's
fault.
Rationale 4: Answer option 4 is correct because the nurse should not have raised the side rails if the client has a
history of dementia and tends to wander, because it increases the risk of serious injury. The nurse in option 1
might have an ethical responsibility to act, but does not have a duty to the client involved in the accident, and so
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

cannot be found negligent. The nurse in option 2 created no harm, which must exist in order to find the nurse
negligent. The nurse in option 3 acted in the client's best interest. Pressure ulcers might not always be preventable
in clients who are severely malnourished or have very poor perfusion, so the client's harm was not the nurse's
fault.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Describe aspects of law that affect nursing practice, including the difference between crimes
and torts, and give examples in nursing.
Question 2
Type: MCSA
When caring for a client with the nursing diagnosis of Falls, risk for, a priority of nursing care to reduce a
successful charge of negligence should the client fall would include which of the following?
1. A friendly relationship with the injured client
2. Documentation demonstrating the standard of care was followed
3. The client recovers fully from the injuries without lasting harm.
4. Promptly informing the family of the client's fall and condition
Correct Answer: 2
Rationale 1: One of the best means of avoiding legal action is through proper documentation of care and strict
adherence to facility policies and standards of care. The other options might not impact the decision to pursue a
lawsuit.
Rationale 2: One of the best means of avoiding legal action is through proper documentation of care and strict
adherence to facility policies and standards of care. The other options might not impact the decision to pursue a
lawsuit.
Rationale 3: One of the best means of avoiding legal action is through proper documentation of care and strict
adherence to facility policies and standards of care. The other options might not impact the decision to pursue a
lawsuit.
Rationale 4: One of the best means of avoiding legal action is through proper documentation of care and strict
adherence to facility policies and standards of care. The other options might not impact the decision to pursue a
lawsuit.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Applying


Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe regulation of nursing practice, standards of care, agency policies, and nurse
practice acts that affect the scope of nursing practice.
Question 3
Type: MCSA
The nursing student, while employed as an unlicensed assistive personnel (UAP) on weekends, is asked to change
a sterile dressing for a postoperative client. The student has demonstrated competence in dressing changes, and
has been signed off on the skill while attending school. Which of the following actions should the UAP take?
1. Change the dressing but ask the nurse to supervise.
2. Call the instructor to ask advice on the matter.
3. Tell the staff nurse that changing a sterile dressing is outside the scope of practice for a UAP.
4. Notify the nursing supervisor of the nurse's request and complete an incident report.
Correct Answer: 3
Rationale 1: Answer option 3 is correct because the student is currently working as a UAP, not a nursing student,
so changing a sterile dressing would be outside the student's scope of practice. Option 1 is incorrect because the
student is not functioning as a nursing student, so both the UAP and nurse could be liable for allowing the
dressing change to be performed by an unlicensed person. Option 2 and 4 are unnecessary because the UAP
should understand the rules and scope of practice.
Rationale 2: Answer option 3 is correct because the student is currently working as a UAP, not a nursing student,
so changing a sterile dressing would be outside the student's scope of practice. Option 1 is incorrect because the
student is not functioning as a nursing student, so both the UAP and nurse could be liable for allowing the
dressing change to be performed by an unlicensed person. Option 2 and 4 are unnecessary because the UAP
should understand the rules and scope of practice.
Rationale 3: Answer option 3 is correct because the student is currently working as a UAP, not a nursing student,
so changing a sterile dressing would be outside the student's scope of practice. Option 1 is incorrect because the
student is not functioning as a nursing student, so both the UAP and nurse could be liable for allowing the
dressing change to be performed by an unlicensed person. Option 2 and 4 are unnecessary because the UAP
should understand the rules and scope of practice.
Rationale 4: Answer option 3 is correct because the student is currently working as a UAP, not a nursing student,
so changing a sterile dressing would be outside the student's scope of practice. Option 1 is incorrect because the
student is not functioning as a nursing student, so both the UAP and nurse could be liable for allowing the
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

dressing change to be performed by an unlicensed person. Option 2 and 4 are unnecessary because the UAP
should understand the rules and scope of practice.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe regulation of nursing practice, standards of care, agency policies, and nurse
practice acts that affect the scope of nursing practice.
Question 4
Type: MCSA
The nurse drives by an accident on the way home from work and does not stop to help because the child care
agency is about to close. One of the victims recognizes the nurse and attempts to bring suit against the nurse.
Which of the following is the correct statement regarding this situation?
1. The nurse cannot be held liable, because there was no duty to the victims.
2. The nurse is liable for any further injuries the victims sustained after driving by the accident.
3. The nurse can be held liable for failure to act.
4. The nurse would only be liable if she stopped to help and did something wrong.
Correct Answer: 1
Rationale 1: Answer option 1 is correct because the nurse had no legal duty to the victims of the accident,
although it could be debated whether there was an ethical obligation to help. Option 2 is not correct, because the
nurse had no duty to act and did not provide care. Option 3 is incorrect because there was no duty for the nurse to
stop. There are states, and provinces in Canada, that do require any citizen to stop and give aid to those in danger.
Option 4 is not correct, because the Good Samaritan law protects any person who aids a victim, provided she acts
in a reasonable and prudent manner.
Rationale 2: Answer option 1 is correct because the nurse had no legal duty to the victims of the accident,
although it could be debated whether there was an ethical obligation to help. Option 2 is not correct, because the
nurse had no duty to act and did not provide care. Option 3 is incorrect because there was no duty for the nurse to
stop. There are states, and provinces in Canada, that do require any citizen to stop and give aid to those in danger.
Option 4 is not correct, because the Good Samaritan law protects any person who aids a victim, provided she acts
in a reasonable and prudent manner.
Rationale 3: Answer option 1 is correct because the nurse had no legal duty to the victims of the accident,
although it could be debated whether there was an ethical obligation to help. Option 2 is not correct, because the
nurse had no duty to act and did not provide care. Option 3 is incorrect because there was no duty for the nurse to
stop. There are states, and provinces in Canada, that do require any citizen to stop and give aid to those in danger.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Option 4 is not correct, because the Good Samaritan law protects any person who aids a victim, provided she acts
in a reasonable and prudent manner.
Rationale 4: Answer option 1 is correct because the nurse had no legal duty to the victims of the accident,
although it could be debated whether there was an ethical obligation to help. Option 2 is not correct, because the
nurse had no duty to act and did not provide care. Option 3 is incorrect because there was no duty for the nurse to
stop. There are states, and provinces in Canada, that do require any citizen to stop and give aid to those in danger.
Option 4 is not correct, because the Good Samaritan law protects any person who aids a victim, provided she acts
in a reasonable and prudent manner.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Define unprofessional conduct: negligence, assault/battery, false imprisonment, invasion of
privacy, and defamation.
Question 5
Type: MCSA
The nurse is caring for an older client who lives with his daughter and is asked by the daughter what the morning
lab results were. The nurse's best response is:
1. "Just a minute. Let me just get his chart."
2. "The doctor will give you the results when he visits."
3. "Let me get my instructor to see if it is alright to do this."
4. "I cannot legally share that information unless your father consents."
Correct Answer: 4
Rationale 1: The nurse cannot legally share privileged information with the daughter unless the client has signed
a form giving consent to share medical information with the daughter.
Rationale 2: The nurse cannot legally share privileged information with the daughter unless the client has signed
a form giving consent to share medical information with the daughter.
Rationale 3: The nurse cannot legally share privileged information with the daughter unless the client has signed
a form giving consent to share medical information with the daughter.
Rationale 4: The nurse cannot legally share privileged information with the daughter unless the client has signed
a form giving consent to share medical information with the daughter.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss several legal aspects of nursing practice, including privileged communication in the
nurse-client relationship.
Question 6
Type: MCSA
The nurse working on a pediatric unit is caring for an infant who lost a large quantity of blood during an accident.
The physician believes the child will die without a blood transfusion, and explains that the infant is too critical to
attempt other measures to increase the child's blood count. The parents refuse to allow the transfusion because it
goes against their beliefs as Jehovah's Witnesses. Following ethical and legal principles, the nurse anticipates
which of the following?
1. The physician will seek a court order to administer blood.
2. The parents' beliefs will be respected, and the infant might die.
3. The physician will order administration of medication to stimulate red blood cell production.
4. The physician will continue to try to change one parent's mind.
Correct Answer: 1
Rationale 1: The client in this scenario is an infant, so a court order will likely be pursed allowing the physician
to administer blood to the child. Every attempt will be made to give only the smallest amount of blood necessary
to save the infant's life out of respect for the family's beliefs. The health care team's first obligation is to the client
(the infant), who is unable to speak for himself.
Rationale 2: The client in this scenario is an infant, so a court order will likely be pursed allowing the physician
to administer blood to the child. Every attempt will be made to give only the smallest amount of blood necessary
to save the infant's life out of respect for the family's beliefs. The health care team's first obligation is to the client
(the infant), who is unable to speak for himself.
Rationale 3: The client in this scenario is an infant, so a court order will likely be pursed allowing the physician
to administer blood to the child. Every attempt will be made to give only the smallest amount of blood necessary
to save the infant's life out of respect for the family's beliefs. The health care team's first obligation is to the client
(the infant), who is unable to speak for himself.
Rationale 4: The client in this scenario is an infant, so a court order will likely be pursed allowing the physician
to administer blood to the child. Every attempt will be made to give only the smallest amount of blood necessary
to save the infant's life out of respect for the family's beliefs. The health care team's first obligation is to the client
(the infant), who is unable to speak for himself.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Explain the purposes and limitations of professional codes of ethics and how they relate to
nursing practice.
Question 7
Type: MCSA
The nurse working on a pediatric unit is reviewing a medication order for an assigned child. The physician's order
is illegible and incomplete. The nurse would do which of the following as a priority action?
1. Call the physician and ask him to clarify the order.
2. Fax the order to the pharmacy, which will clarify the order with the physician.
3. Give the order to the unit secretary, who will clarify the order with the physician.
4. Give the medication as interpreted so as not to disrupt client care.
Correct Answer: 1
Rationale 1: In the role of an advocate for the client, the nurse has the obligation to clarify the order and reduce
the risk of a medication error that might be incurred by guessing what the order says. Even if the pharmacy or unit
secretary interpreted the illegible handwriting, the nurse could not give the medication without independently
being certain it was properly interpreted. The nurse should speak to the physician and seek clarification.
Rationale 2: In the role of an advocate for the client, the nurse has the obligation to clarify the order and reduce
the risk of a medication error that might be incurred by guessing what the order says. Even if the pharmacy or unit
secretary interpreted the illegible handwriting, the nurse could not give the medication without independently
being certain it was properly interpreted. The nurse should speak to the physician and seek clarification.
Rationale 3: In the role of an advocate for the client, the nurse has the obligation to clarify the order and reduce
the risk of a medication error that might be incurred by guessing what the order says. Even if the pharmacy or unit
secretary interpreted the illegible handwriting, the nurse could not give the medication without independently
being certain it was properly interpreted. The nurse should speak to the physician and seek clarification.
Rationale 4: In the role of an advocate for the client, the nurse has the obligation to clarify the order and reduce
the risk of a medication error that might be incurred by guessing what the order says. Even if the pharmacy or unit
secretary interpreted the illegible handwriting, the nurse could not give the medication without independently
being certain it was properly interpreted. The nurse should speak to the physician and seek clarification.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Applying


Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Discuss the advocacy role of the nurse.
Question 8
Type: MCSA
The nurse is faced with making an ethical decision regarding the care of the assigned client. Which of the
following actions would be helpful to the nurse in making the right decision?
1. Discuss the dilemma with the client's family.
2. Call the Board of Nursing for assistance.
3. Contact the Legal Department of the agency.
4. Contact the agency ethics committee for assistance.
Correct Answer: 4
Rationale 1: The facility ethics committee functions to help resolve ethical dilemmas regarding client care.
Discussing the dilemma with the family would be illegal and a breach of privacy. The Board of Nursing and Legal
Department might offer legal advice, but would not be the best source for ethical decision making.
Rationale 2: The facility ethics committee functions to help resolve ethical dilemmas regarding client care.
Discussing the dilemma with the family would be illegal and a breach of privacy. The Board of Nursing and Legal
Department might offer legal advice, but would not be the best source for ethical decision making.
Rationale 3: The facility ethics committee functions to help resolve ethical dilemmas regarding client care.
Discussing the dilemma with the family would be illegal and a breach of privacy. The Board of Nursing and Legal
Department might offer legal advice, but would not be the best source for ethical decision making.
Rationale 4: The facility ethics committee functions to help resolve ethical dilemmas regarding client care.
Discussing the dilemma with the family would be illegal and a breach of privacy. The Board of Nursing and Legal
Department might offer legal advice, but would not be the best source for ethical decision making.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss approaches to making ethical decisions.
Question 9
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Type: MCSA
The nurse finds a medication error made on a prior shift by another nurse. The nurse who discovers the error will:
1. Write a note to the nurse involved explaining the need for an incident report.
2. Ignore the error because it's none of the nurse's business.
3. Report the error to the nursing supervisor to deal with the incident report.
4. Complete an incident report according to facility policy.
Correct Answer: 4
Rationale 1: An incident report is completed by the person who discovers the incident, which does not indicate
responsibility for the event. The nursing supervisor should be informed of the incident report and error, but will
not be responsible for completing the incident report.
Rationale 2: An incident report is completed by the person who discovers the incident, which does not indicate
responsibility for the event. The nursing supervisor should be informed of the incident report and error, but will
not be responsible for completing the incident report.
Rationale 3: An incident report is completed by the person who discovers the incident, which does not indicate
responsibility for the event. The nursing supervisor should be informed of the incident report and error, but will
not be responsible for completing the incident report.
Rationale 4: An incident report is completed by the person who discovers the incident, which does not indicate
responsibility for the event. The nursing supervisor should be informed of the incident report and error, but will
not be responsible for completing the incident report.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: List information that needs to be included in an incident report.
Question 10
Type: MCMA
The nurse working on a mental health unit is caring for a client who is becoming agitated. The nurse prepares an
ordered sedative for the client, but the client declines to take it. The nurse says to the client, "If you don't take this
orally, I'll give it to you by injection." When the client continues to refuse the medication, the nurse administers
the injection. The nurse could be found guilty of: (Select all that apply.)
Standard Text: Select all that apply.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Slander.
2. Libel.
3. False imprisonment.
4. Battery.
5. Invasion of privacy.
Correct Answer: 3,4
Rationale 1: The nurse is using a chemical restraint without the permission of the client, so the nurse could be
found guilty of battery (willful touching of a person) and false imprisonment (unlawful restraint of the client
against his wishes). Slander (defamation by spoken word) and libel (defamation by written word) involve false
communication, which does not apply to this scenario. Invasion of privacy is revealing something private the
person prefers to keep confidential, and does not apply to this scenario.
Rationale 2: The nurse is using a chemical restraint without the permission of the client, so the nurse could be
found guilty of battery (willful touching of a person) and false imprisonment (unlawful restraint of the client
against his wishes). Slander (defamation by spoken word) and libel (defamation by written word) involve false
communication, which does not apply to this scenario. Invasion of privacy is revealing something private the
person prefers to keep confidential, and does not apply to this scenario.
Rationale 3: The nurse is using a chemical restraint without the permission of the client, so the nurse could be
found guilty of battery (willful touching of a person) and false imprisonment (unlawful restraint of the client
against his wishes). Slander (defamation by spoken word) and libel (defamation by written word) involve false
communication, which does not apply to this scenario. Invasion of privacy is revealing something private the
person prefers to keep confidential, and does not apply to this scenario.
Rationale 4: The nurse is using a chemical restraint without the permission of the client, so the nurse could be
found guilty of battery (willful touching of a person) and false imprisonment (unlawful restraint of the client
against his wishes). Slander (defamation by spoken word) and libel (defamation by written word) involve false
communication, which does not apply to this scenario. Invasion of privacy is revealing something private the
person prefers to keep confidential, and does not apply to this scenario.
Rationale 5: The nurse is using a chemical restraint without the permission of the client, so the nurse could be
found guilty of battery (willful touching of a person) and false imprisonment (unlawful restraint of the client
against his wishes). Slander (defamation by spoken word) and libel (defamation by written word) involve false
communication, which does not apply to this scenario. Invasion of privacy is revealing something private the
person prefers to keep confidential, and does not apply to this scenario.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome: Define unprofessional conduct: negligence, assault/battery, false imprisonment, invasion of
privacy, and defamation.
Question 11
Type: MCSA
The nurse, while driving home from work, stops to render aid at the scene of an accident. Which of the following
would demonstrate appropriate nursing action?
1. Provide all the care you assess that the client needs in order to save her life.
2. Do nothing and stay with the victims until help arrives.
3. Give first aid based on the nurse's competency and nurse practice act.
4. Leave the scene if it appears the client needs help the nurse can't provide, and call 911.
Correct Answer: 3
Rationale 1: Answer option 3 is correct because the Good Samaritan law will protect the nurse who gives care
that any other reasonable nurse would give and that does not exceed the nurse's level of competence or the state
nurse practice act. Option 1 is incorrect because some client needs might exceed the nurse's ability and scope of
practice. Option 2 is incorrect as well, because the nurse who stops should give basic first aid until help arrives.
The nurse never leaves the victim until professional rescuers arrive (option 4).
Rationale 2: Answer option 3 is correct because the Good Samaritan law will protect the nurse who gives care
that any other reasonable nurse would give and that does not exceed the nurse's level of competence or the state
nurse practice act. Option 1 is incorrect because some client needs might exceed the nurse's ability and scope of
practice. Option 2 is incorrect as well, because the nurse who stops should give basic first aid until help arrives.
The nurse never leaves the victim until professional rescuers arrive (option 4).
Rationale 3: Answer option 3 is correct because the Good Samaritan law will protect the nurse who gives care
that any other reasonable nurse would give and that does not exceed the nurse's level of competence or the state
nurse practice act. Option 1 is incorrect because some client needs might exceed the nurse's ability and scope of
practice. Option 2 is incorrect as well, because the nurse who stops should give basic first aid until help arrives.
The nurse never leaves the victim until professional rescuers arrive (option 4).
Rationale 4: Answer option 3 is correct because the Good Samaritan law will protect the nurse who gives care
that any other reasonable nurse would give and that does not exceed the nurse's level of competence or the state
nurse practice act. Option 1 is incorrect because some client needs might exceed the nurse's ability and scope of
practice. Option 2 is incorrect as well, because the nurse who stops should give basic first aid until help arrives.
The nurse never leaves the victim until professional rescuers arrive (option 4).
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Client Need Sub:


Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Describe legal protection for nurses, including Good Samaritan and the Americans with
Disabilities acts.
Question 12
Type: MCSA
The nurse receives an order from the primary care provider that the nurse believes would be harmful to the client.
What should the nurse do to meet her legal obligation to the client?
1. Carry out the order as written, because the provider knows best.
2. Document in the medical record that the order wasn't carried out, and why.
3. Contact the supervisor to discuss the order and the nurse's concerns.
4. Just ignore the order, and document that it was not carried out.
Correct Answer: 3
Rationale 1: While the nurse has an obligation to carry out the provider's orders, the obligation to the client is
more important. A nurse who carries out an order that harms the client shares the same liability and responsibility
as the provider, so the nurse must consult the supervisor to discuss the order and the nurse's concern. If the
supervisor cannot satisfactorily explain the safety of the order, the physician must be consulted. Ignoring the order
would not serve the client, and disagreements with the plan of care are not documented in the legal record but
resolved between members of the health care team.
Rationale 2: While the nurse has an obligation to carry out the provider's orders, the obligation to the client is
more important. A nurse who carries out an order that harms the client shares the same liability and responsibility
as the provider, so the nurse must consult the supervisor to discuss the order and the nurse's concern. If the
supervisor cannot satisfactorily explain the safety of the order, the physician must be consulted. Ignoring the order
would not serve the client, and disagreements with the plan of care are not documented in the legal record but
resolved between members of the health care team.
Rationale 3: While the nurse has an obligation to carry out the provider's orders, the obligation to the client is
more important. A nurse who carries out an order that harms the client shares the same liability and responsibility
as the provider, so the nurse must consult the supervisor to discuss the order and the nurse's concern. If the
supervisor cannot satisfactorily explain the safety of the order, the physician must be consulted. Ignoring the order
would not serve the client, and disagreements with the plan of care are not documented in the legal record but
resolved between members of the health care team.
Rationale 4: While the nurse has an obligation to carry out the provider's orders, the obligation to the client is
more important. A nurse who carries out an order that harms the client shares the same liability and responsibility
as the provider, so the nurse must consult the supervisor to discuss the order and the nurse's concern. If the
supervisor cannot satisfactorily explain the safety of the order, the physician must be consulted. Ignoring the order
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

would not serve the client, and disagreements with the plan of care are not documented in the legal record but
resolved between members of the health care team.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Discuss several legal aspects of nursing practice, including privileged communication in the
nurse-client relationship.
Question 13
Type: MCSA
A client with serious medical problems wants to leave the hospital without a physician's discharge order. The
client is mentally competent. Legally, the priority nursing action is which of the following?
1. Administer a sedative to keep him from leaving.
2. Find out why the client is leaving, and correct the situation so he will stay.
3. Notify the nursing supervisor.
4. Notify the client's family about the situation.
Correct Answer: 3
Rationale 1: Answer option 3 is correct because legally, the client has the right to refuse care, and may leave the
hospital if he chooses. The nursing supervisor should be notified so the legal interests of the facility, as well as the
client's best interest, can be served. The supervisor will explain to the client what could result from his decision
and have the client sign an against medical advice (AMA) form. Restraining the client (a sedative is a chemical
restraint) is false imprisonment and against the law. If the client chooses to leave anyway, the nurse has increased
the danger to the client due to the administration of the sedative. Option 2 is incorrect because the reason the
client is leaving is likely beyond the capacity of the nurse to correct. Option 4 is incorrect because this is an
invasion of the client's privacy.
Rationale 2: Answer option 3 is correct because legally, the client has the right to refuse care, and may leave the
hospital if he chooses. The nursing supervisor should be notified so the legal interests of the facility, as well as the
client's best interest, can be served. The supervisor will explain to the client what could result from his decision
and have the client sign an against medical advice (AMA) form. Restraining the client (a sedative is a chemical
restraint) is false imprisonment and against the law. If the client chooses to leave anyway, the nurse has increased
the danger to the client due to the administration of the sedative. Option 2 is incorrect because the reason the
client is leaving is likely beyond the capacity of the nurse to correct. Option 4 is incorrect because this is an
invasion of the client's privacy.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: Answer option 3 is correct because legally, the client has the right to refuse care, and may leave the
hospital if he chooses. The nursing supervisor should be notified so the legal interests of the facility, as well as the
client's best interest, can be served. The supervisor will explain to the client what could result from his decision
and have the client sign an against medical advice (AMA) form. Restraining the client (a sedative is a chemical
restraint) is false imprisonment and against the law. If the client chooses to leave anyway, the nurse has increased
the danger to the client due to the administration of the sedative. Option 2 is incorrect because the reason the
client is leaving is likely beyond the capacity of the nurse to correct. Option 4 is incorrect because this is an
invasion of the client's privacy.
Rationale 4: Answer option 3 is correct because legally, the client has the right to refuse care, and may leave the
hospital if he chooses. The nursing supervisor should be notified so the legal interests of the facility, as well as the
client's best interest, can be served. The supervisor will explain to the client what could result from his decision
and have the client sign an against medical advice (AMA) form. Restraining the client (a sedative is a chemical
restraint) is false imprisonment and against the law. If the client chooses to leave anyway, the nurse has increased
the danger to the client due to the administration of the sedative. Option 2 is incorrect because the reason the
client is leaving is likely beyond the capacity of the nurse to correct. Option 4 is incorrect because this is an
invasion of the client's privacy.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Describe aspects of law that affect nursing practice, including the difference between crimes
and torts, and give examples in nursing.
Question 14
Type: MCSA
A client arrives in the Emergency Department with a gunshot wound, and the nursing staff shares information
with the police regarding the client's injuries. In addition, information regarding the client and the injuries are
reported to the health department. The actions of the staff could be best described by which of the following?
1. Breach of confidentiality
2. Invasion of privacy
3. Obligation to report
4. Unprofessional conduct
Correct Answer: 3
Rationale 1: The nurse and health care team have the legal obligation to report specific conditions, including
gunshot wounds, abuse, and certain communicable diseases, so the nursing staff is allowed to breach client
confidentiality in these instances.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: The nurse and health care team have the legal obligation to report specific conditions, including
gunshot wounds, abuse, and certain communicable diseases, so the nursing staff is allowed to breach client
confidentiality in these instances.
Rationale 3: The nurse and health care team have the legal obligation to report specific conditions, including
gunshot wounds, abuse, and certain communicable diseases, so the nursing staff is allowed to breach client
confidentiality in these instances.
Rationale 4: The nurse and health care team have the legal obligation to report specific conditions, including
gunshot wounds, abuse, and certain communicable diseases, so the nursing staff is allowed to breach client
confidentiality in these instances.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Discuss several legal aspects of nursing practice, including privileged communication in the
nurse-client relationship.
Question 15
Type: MCSA
The client complains of pain, and tells the nurse that the last time he got pain medication, it was dark outside. The
nurse checks the medical record and sees that the day shift nurse documented administering an injection of
narcotic analgesics twice during the day. The client's wife says she was with him all day and he never received an
injection. The nurse's priority action is to:
1. Call the Board of Nursing to notify them of falsification of records.
2. Notify the nursing supervisor immediately of the situation.
3. Call the day shift nurse to ask if the medication was actually given.
4. Complete an incident report.
Correct Answer: 2
Rationale 1: The nursing supervisor should be notified. The nursing supervisor will investigate the situation to
determine what actually occurred. The nurse should not jump to conclusions based on a small amount of
information, so the Board of Nursing should not be notified and an incident report should not be completed at this
time. It is not the nurse's responsibility to call the day shift nurse.
Rationale 2: The nursing supervisor should be notified. The nursing supervisor will investigate the situation to
determine what actually occurred. The nurse should not jump to conclusions based on a small amount of
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

information, so the Board of Nursing should not be notified and an incident report should not be completed at this
time. It is not the nurse's responsibility to call the day shift nurse.
Rationale 3: The nursing supervisor should be notified. The nursing supervisor will investigate the situation to
determine what actually occurred. The nurse should not jump to conclusions based on a small amount of
information, so the Board of Nursing should not be notified and an incident report should not be completed at this
time. It is not the nurse's responsibility to call the day shift nurse.
Rationale 4: The nursing supervisor should be notified. The nursing supervisor will investigate the situation to
determine what actually occurred. The nurse should not jump to conclusions based on a small amount of
information, so the Board of Nursing should not be notified and an incident report should not be completed at this
time. It is not the nurse's responsibility to call the day shift nurse.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Explain the purposes and limitations of professional codes of ethics and how they relate to
nursing practice.
Question 16
Type: MCSA
The nurse enters the client's room to obtain consent for a procedure to be performed tomorrow. When the nurse
asks if the client has any questions, the client says, "Well, I didn't hear everything the doctor said, but I will still
sign the consent." What is the nurse's priority action?
1. Notify the physician immediately.
2. Explain the part of the information the client did not understand.
3. Obtain a written handout explaining the procedure.
4. Allow the client to sign the consent form.
Correct Answer: 1
Rationale 1: While the nurse's only responsibility regarding consents is to witness the signature, the nurse's role
as advocate for the client dictates that a client not be allowed to sign the consent without fully understanding the
procedure to be performed. The nurse should require the physician to explain the procedure to the client's
understanding before allowing the consent to be signed. The nurse does not explain the procedure; it must be
explained by the person who will perform it.
Rationale 2: While the nurse's only responsibility regarding consents is to witness the signature, the nurse's role
as advocate for the client dictates that a client not be allowed to sign the consent without fully understanding the
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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procedure to be performed. The nurse should require the physician to explain the procedure to the client's
understanding before allowing the consent to be signed. The nurse does not explain the procedure; it must be
explained by the person who will perform it.
Rationale 3: While the nurse's only responsibility regarding consents is to witness the signature, the nurse's role
as advocate for the client dictates that a client not be allowed to sign the consent without fully understanding the
procedure to be performed. The nurse should require the physician to explain the procedure to the client's
understanding before allowing the consent to be signed. The nurse does not explain the procedure; it must be
explained by the person who will perform it.
Rationale 4: While the nurse's only responsibility regarding consents is to witness the signature, the nurse's role
as advocate for the client dictates that a client not be allowed to sign the consent without fully understanding the
procedure to be performed. The nurse should require the physician to explain the procedure to the client's
understanding before allowing the consent to be signed. The nurse does not explain the procedure; it must be
explained by the person who will perform it.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Identify ways nurses and nursing students can minimize their chances of liability.
Question 17
Type: MCSA
The nurse sees a visitor exit a client's room into the hallway and faint, falling on the floor unconscious. The nurse
has the visitor taken to the Emergency Department, notifies the supervisor, and completes an incident report. The
nurse's next action is to:
1. Document in the chart of the client whose room the visitor exited that an event occurred, and describe the event
objectively.
2. Initiate a new client medical record for the visitor and document the event objectively.
3. Give the completed report to the nursing supervisor.
4. File the incident report in the chart of the client whose room the visitor exited.
Correct Answer: 3
Rationale 1: When a visitor to the hospital is involved in an event, the incident report is given to the nursing
supervisor, just as it would be if the person involved were a client. The visitor should always be encouraged to be
seen in the Emergency Department so that he receives immediate care for any injury he might have sustained.
Nothing should be documented in the client's record, because the medical record only pertains to the client, not
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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visitors. A medical record for the visitor will be initiated in the Emergency Departmentthe nurse does not
initiate it.
Rationale 2: When a visitor to the hospital is involved in an event, the incident report is given to the nursing
supervisor, just as it would be if the person involved were a client. The visitor should always be encouraged to be
seen in the Emergency Department so that he receives immediate care for any injury he might have sustained.
Nothing should be documented in the client's record, because the medical record only pertains to the client, not
visitors. A medical record for the visitor will be initiated in the Emergency Departmentthe nurse does not
initiate it.
Rationale 3: When a visitor to the hospital is involved in an event, the incident report is given to the nursing
supervisor, just as it would be if the person involved were a client. The visitor should always be encouraged to be
seen in the Emergency Department so that he receives immediate care for any injury he might have sustained.
Nothing should be documented in the client's record, because the medical record only pertains to the client, not
visitors. A medical record for the visitor will be initiated in the Emergency Departmentthe nurse does not
initiate it.
Rationale 4: When a visitor to the hospital is involved in an event, the incident report is given to the nursing
supervisor, just as it would be if the person involved were a client. The visitor should always be encouraged to be
seen in the Emergency Department so that he receives immediate care for any injury he might have sustained.
Nothing should be documented in the client's record, because the medical record only pertains to the client, not
visitors. A medical record for the visitor will be initiated in the Emergency Departmentthe nurse does not
initiate it.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: List information that needs to be included in an incident report.
Question 18
Type: MCMA
When the nursing student prepares to administer an injectable medication to a client for the first time, after
practicing in the skills lab, the student should do which of the following? Select all that apply.
Standard Text: Select all that apply.
1. Establish a therapeutic relationship with the client and family.
2. Review the facility policy on medication administration.
3. Explain the procedure to the client.
4. Request supervision from the instructor.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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5. Call the physician to verify the order.


Correct Answer: 2,3,4
Rationale 1: Procedures can vary slightly from facility to facility, so it is important for the student to review the
facility policy before administering the medication. When a nursing student is performing a skill for the first time,
or until competence is determined, the nursing instructor should always supervise the procedure. The client should
not be touched without first explaining what will be done and why it is being done. The order does not need to be
verified with the physician unless there is a problem with the order. A therapeutic relationship with the client and
family is optimal, but it is not required in this situation.
Rationale 2: Procedures can vary slightly from facility to facility, so it is important for the student to review the
facility policy before administering the medication. When a nursing student is performing a skill for the first time,
or until competence is determined, the nursing instructor should always supervise the procedure. The client should
not be touched without first explaining what will be done and why it is being done. The order does not need to be
verified with the physician unless there is a problem with the order. A therapeutic relationship with the client and
family is optimal, but it is not required in this situation.
Rationale 3: Procedures can vary slightly from facility to facility, so it is important for the student to review the
facility policy before administering the medication. When a nursing student is performing a skill for the first time,
or until competence is determined, the nursing instructor should always supervise the procedure. The client should
not be touched without first explaining what will be done and why it is being done. The order does not need to be
verified with the physician unless there is a problem with the order. A therapeutic relationship with the client and
family is optimal, but it is not required in this situation.
Rationale 4: Procedures can vary slightly from facility to facility, so it is important for the student to review the
facility policy before administering the medication. When a nursing student is performing a skill for the first time,
or until competence is determined, the nursing instructor should always supervise the procedure. The client should
not be touched without first explaining what will be done and why it is being done. The order does not need to be
verified with the physician unless there is a problem with the order. A therapeutic relationship with the client and
family is optimal, but it is not required in this situation.
Rationale 5: Procedures can vary slightly from facility to facility, so it is important for the student to review the
facility policy before administering the medication. When a nursing student is performing a skill for the first time,
or until competence is determined, the nursing instructor should always supervise the procedure. The client should
not be touched without first explaining what will be done and why it is being done. The order does not need to be
verified with the physician unless there is a problem with the order. A therapeutic relationship with the client and
family is optimal, but it is not required in this situation.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Identify ways nurses and nursing students can minimize their chances of liability.
Question 19
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Type: MCSA
Several staff nurses are talking about liability insurance at the nurse's desk. Which statement, made by the nurses,
reflects an understanding of the purpose of liability insurance?
1. "I was told that the hospital carries liability insurance on its employees, so I don't need to carry my own policy."
2. "I have not gotten insurance because doctors and hospitals get sued more than nurses."
3. "I am a good nurse, and practice safely, so I don't need liability insurance."
4. "I carry my own liability insurance because hospitals can countersue nurses."
Correct Answer: 4
Rationale 1: Answer option 4 is the correct answer because the hospital can countersue the nurse if a grievous
error is committed. While the hospital might carry insurance for the nurse, it does not cover the nurse when
working outside of the facility, such as in screening clinics, in parish nursing, or providing care at the scene of an
accident. Nurses can be and are frequently included in lawsuits as well as doctors and hospitals. While all nurses
strive to provide safe and effective nursing care, accidents and mistakes can happen. Liability insurance helps to
protect the nurse in those situations.
Rationale 2: Answer option 4 is the correct answer because the hospital can countersue the nurse if a grievous
error is committed. While the hospital might carry insurance for the nurse, it does not cover the nurse when
working outside of the facility, such as in screening clinics, in parish nursing, or providing care at the scene of an
accident. Nurses can be and are frequently included in lawsuits as well as doctors and hospitals. While all nurses
strive to provide safe and effective nursing care, accidents and mistakes can happen. Liability insurance helps to
protect the nurse in those situations.
Rationale 3: Answer option 4 is the correct answer because the hospital can countersue the nurse if a grievous
error is committed. While the hospital might carry insurance for the nurse, it does not cover the nurse when
working outside of the facility, such as in screening clinics, in parish nursing, or providing care at the scene of an
accident. Nurses can be and are frequently included in lawsuits as well as doctors and hospitals. While all nurses
strive to provide safe and effective nursing care, accidents and mistakes can happen. Liability insurance helps to
protect the nurse in those situations.
Rationale 4: Answer option 4 is the correct answer because the hospital can countersue the nurse if a grievous
error is committed. While the hospital might carry insurance for the nurse, it does not cover the nurse when
working outside of the facility, such as in screening clinics, in parish nursing, or providing care at the scene of an
accident. Nurses can be and are frequently included in lawsuits as well as doctors and hospitals. While all nurses
strive to provide safe and effective nursing care, accidents and mistakes can happen. Liability insurance helps to
protect the nurse in those situations.
Global Rationale:
Cognitive Level: Understanding
Client Need:
Client Need Sub:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Nursing/Integrated Concepts:
Learning Outcome: Explain the purpose of liability insurance.
Question 20
Type: MCSA
The nurse enters the client's room and finds the client sitting on the floor beside the bed. The nurse asks the client
if he fell, and the client denies a fall. Which of the following actions should the nurse take?
1. Leave the client on the floor and get another nurse to witness the event.
2. Assess the client and complete an incident report.
3. Document in the chart that the client fell out of bed.
4. Accept the client's statement that she did not fall.
Correct Answer: 2
Rationale 1: The nurse should first assess the client and provide any needed care. Once the client is cared for, the
nurse should complete an incident report, because the client was found on the floor. While it is possible the client
chose to sit on the floor, it is not likely; an incident report would be the safest action to take, and will cause no
harm if the client indeed chose to sit on the floor. Answer option 1 is incorrect because it requires the client to
remain on the floor, possibly injured, and there is no need for a witness. Option 3 is incorrect because the nurse
should document objectively, and did not witness the client fall out of bed. The correct wording would be "Client
found sitting on floor, denies falling." Option 4 is not acceptable, because of the high likelihood that the client
might have fallen. Completing an incident report will not cause a problem if the client did not actually fall, and
can be important if problems arise later.
Rationale 2: The nurse should first assess the client and provide any needed care. Once the client is cared for, the
nurse should complete an incident report, because the client was found on the floor. While it is possible the client
chose to sit on the floor, it is not likely; an incident report would be the safest action to take, and will cause no
harm if the client indeed chose to sit on the floor. Answer option 1 is incorrect because it requires the client to
remain on the floor, possibly injured, and there is no need for a witness. Option 3 is incorrect because the nurse
should document objectively, and did not witness the client fall out of bed. The correct wording would be "Client
found sitting on floor, denies falling." Option 4 is not acceptable, because of the high likelihood that the client
might have fallen. Completing an incident report will not cause a problem if the client did not actually fall, and
can be important if problems arise later.
Rationale 3: The nurse should first assess the client and provide any needed care. Once the client is cared for, the
nurse should complete an incident report, because the client was found on the floor. While it is possible the client
chose to sit on the floor, it is not likely; an incident report would be the safest action to take, and will cause no
harm if the client indeed chose to sit on the floor. Answer option 1 is incorrect because it requires the client to
remain on the floor, possibly injured, and there is no need for a witness. Option 3 is incorrect because the nurse
should document objectively, and did not witness the client fall out of bed. The correct wording would be "Client
found sitting on floor, denies falling." Option 4 is not acceptable, because of the high likelihood that the client
might have fallen. Completing an incident report will not cause a problem if the client did not actually fall, and
can be important if problems arise later.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: The nurse should first assess the client and provide any needed care. Once the client is cared for, the
nurse should complete an incident report, because the client was found on the floor. While it is possible the client
chose to sit on the floor, it is not likely; an incident report would be the safest action to take, and will cause no
harm if the client indeed chose to sit on the floor. Answer option 1 is incorrect because it requires the client to
remain on the floor, possibly injured, and there is no need for a witness. Option 3 is incorrect because the nurse
should document objectively, and did not witness the client fall out of bed. The correct wording would be "Client
found sitting on floor, denies falling." Option 4 is not acceptable, because of the high likelihood that the client
might have fallen. Completing an incident report will not cause a problem if the client did not actually fall, and
can be important if problems arise later.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: List information that needs to be included in an incident report.
Question 21
Type: MCSA
The nurse transcribes a medication order that is outside the acceptable dosage, and attempts to call the physician
but is unable to reach her. The nurse's most appropriate action is to:
1. Administer the medication as ordered.
2. Withhold the medication until the physician can be reached.
3. Contact the nursing supervisor.
4. Give the proper dosage of the drug.
Correct Answer: 3
Rationale 1: As a client advocate, the nurse's best action is to notify the nursing supervisor, who will assist in
obtaining clarification for the order. Administering the dosage the nurse believes to be correct is prescribing,
which is outside the scope of practice for the nurse and dangerous for the client. Holding the medication could
result in a poor outcome for the client because she would not receive a necessary medication. Administering the
medication as ordered would likely result in harm to the client.
Rationale 2: As a client advocate, the nurse's best action is to notify the nursing supervisor, who will assist in
obtaining clarification for the order. Administering the dosage the nurse believes to be correct is prescribing,
which is outside the scope of practice for the nurse and dangerous for the client. Holding the medication could
result in a poor outcome for the client because she would not receive a necessary medication. Administering the
medication as ordered would likely result in harm to the client.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: As a client advocate, the nurse's best action is to notify the nursing supervisor, who will assist in
obtaining clarification for the order. Administering the dosage the nurse believes to be correct is prescribing,
which is outside the scope of practice for the nurse and dangerous for the client. Holding the medication could
result in a poor outcome for the client because she would not receive a necessary medication. Administering the
medication as ordered would likely result in harm to the client.
Rationale 4: As a client advocate, the nurse's best action is to notify the nursing supervisor, who will assist in
obtaining clarification for the order. Administering the dosage the nurse believes to be correct is prescribing,
which is outside the scope of practice for the nurse and dangerous for the client. Holding the medication could
result in a poor outcome for the client because she would not receive a necessary medication. Administering the
medication as ordered would likely result in harm to the client.
Global Rationale:
Cognitive Level: Analyzing
Client Need: !CN>Physiologic Integrity: Pharmacological Therapies
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Discuss approaches to making ethical decisions.
Question 22
Type: MCSA
The nurse, beginning the shift, is informed of the necessity to float to the adult critical care unit. The nurse works
in pediatrics, and has never worked in a critical care area before. Which of the following actions would be
appropriate for the nurse?
1. Notify the nursing supervisor of the unsafe situation.
2. Inform the charge nurse of the ICU that the nurse will function as a nursing assistant.
3. Refuse to float.
4. Report to the ICU and identify the tasks that the nurse can safely perform.
Correct Answer: 4
Rationale 1: Answer option 4 is the correct response because the nurse can perform basic care in any setting.
Options 1 and 2 are incorrect because the nurse would be unsafe only if unfamiliar tasks were performed. The
nurse's responsibility is to perform only those tasks for which he has been trained. Option 3 is incorrect because
this would be client abandonment.
Rationale 2: Answer option 4 is the correct response because the nurse can perform basic care in any setting.
Options 1 and 2 are incorrect because the nurse would be unsafe only if unfamiliar tasks were performed. The
nurse's responsibility is to perform only those tasks for which he has been trained. Option 3 is incorrect because
this would be client abandonment.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: Answer option 4 is the correct response because the nurse can perform basic care in any setting.
Options 1 and 2 are incorrect because the nurse would be unsafe only if unfamiliar tasks were performed. The
nurse's responsibility is to perform only those tasks for which he has been trained. Option 3 is incorrect because
this would be client abandonment.
Rationale 4: Answer option 4 is the correct response because the nurse can perform basic care in any setting.
Options 1 and 2 are incorrect because the nurse would be unsafe only if unfamiliar tasks were performed. The
nurse's responsibility is to perform only those tasks for which he has been trained. Option 3 is incorrect because
this would be client abandonment.
Global Rationale:
Cognitive Level: Analyzing
Client Need: !CN>Physiological Integrity: Client Care Assignment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss common ethical issues currently facing healthcare professionals.
Question 23
Type: MCSA
Writing in the nurses notes that a physician is incompetent is an example of
1. Slander
2. Malpractice
3. Libel
4. Negligence
Correct Answer: 3
Rationale 1: Slander is defamation by the spoken word, stating information or false words that can cause damage
to a persons reputation
Rationale 2: Malpractice is negligence that occurred while the person was performing as a professional
Rationale 3: Libel is defamation by means of print, writing or pictures
Rationale 4: Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable,
and prudent practitioner, which places another person at risk for harm
Global Rationale:
Cognitive Level: Applying
Client Need:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Client Need Sub:


Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 24
Type: MCMA
In order for a case of nursing malpractice to be proven, which of the following must be proven:
Standard Text: Select all that apply.
1. Duty
2. Breach of duty
3. Causation
4. Harm
5. Negligence
Correct Answer: 1,2,3,4
Rationale 1: The nurse must have a working relationship with the client (duty)
Rationale 2: The nurse must have a working relationship with the client (duty)
Rationale 3: The nurse must have a working relationship with the client (duty)
Rationale 4: The nurse must have a working relationship with the client (duty)
Rationale 5: The nurse must have a working relationship with the client (duty)
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 25
Type: MCMA
Match the category of law affecting nurses with the appropriate example
Standard Text: Select all that apply.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer:
Global Rationale:
Cognitive Level:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 26
Type: MCSA
The regulation of nursing is a function of what kind of law in the United States?
1. Provincial
2. State
3. Federal
4. Contract
Correct Answer: 2
Rationale 1: Provincial law is Canadian.
Rationale 2: The regulation of nursing is a function of state law in the united states. State legislatures pass
statutes that define and regulate nursing called nurse practice acts
Rationale 3: Federal law does not regulate nursing
Rationale 4: Contract law affects nursing, but does not regulate nursing practice
Global Rationale:
Cognitive Level: Understanding
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 27
Type: MCMA
The nurse understands the boundaries of client care regarding intentional torts include
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Standard Text: Select all that apply.


1. Assault
2. Battery
3. False imprisonment
4. Invasion of privacy
5. Misdemeanor
Correct Answer: 1,2,3,4
Rationale 1: Assault can be described as an attempt or threat to touch another person unjustifiably
Rationale 2: Battery is the willful touching of a person that may or may not cause harm
Rationale 3: False imprisonment is the unlawful restraint or detention of another person against his or her wishes
Rationale 4: Invasion of privacy is a direct wrong of a personal nature that injures the feelings of the person and
does not take into account the effect of revealed information on the standing of the person in the community
Rationale 5: A misdemeanor is a criminal offense that is less serious than a felony
Global Rationale:
Cognitive Level: Understanding
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 28
Type: MCMA
The nurse explains the components of credentialing as including
Standard Text: Select all that apply.
1. Licensure
2. Registration
3. Certification
4. Accreditation
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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5. Nurse practice act


Correct Answer: 1,2,3,4
Rationale 1: Licensing is mandatory in in the United States to practice nursing.
Rationale 2: Licensing is mandatory in in the United States to practice nursing.
Rationale 3: Licensing is mandatory in in the United States to practice nursing.
Rationale 4: Licensing is mandatory in in the United States to practice nursing.
Rationale 5: Licensing is mandatory in in the United States to practice nursing.
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 29
Type: MCSA
The nurse has separate, interdependent legal roles that include provider of service, citizen and
1. Supervisor
2. Contractor for services
3. Worker
4. Floater
Correct Answer: 2
Rationale 1: The role of supervisor is not a legal role, it is an employment role
Rationale 2: The role of supervisor is not a legal role, it is an employment role
Rationale 3: The role of supervisor is not a legal role, it is an employment role
Rationale 4: The role of supervisor is not a legal role, it is an employment role
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Applying


Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 30
Type: MCMA
In order to be protected by a Good Samaritan act, the nurse must follow which of the following guidelines
Standard Text: Select all that apply.
1. Limit actions to those normally considered first aid if possible
2. Perform only actions that he or she knows how to do
3. Offer assistance but do not insist
4. Do not leave the scene until the injured person leaves or another qualified person takes over
5. Do whatever needs to be done to save the injured persons life
Correct Answer: 1,2,3,4
Rationale 1: Limiting ones actions to first aid
Rationale 2: Limiting ones actions to first aid
Rationale 3: Limiting ones actions to first aid
Rationale 4: Limiting ones actions to first aid
Rationale 5: Limiting ones actions to first aid
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 31
Type: MCSA
Which of the following actions will assist in protecting the nurse from legal action?
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Recording client information in the chart at the end of the shift


2. Delegate as much client care as possible
3. Assure clients that you know what is best for them
4. Ask for assistance
Correct Answer: 4
Rationale 1: Recording should be done promptly and accurately
Rationale 2: Recording should be done promptly and accurately
Rationale 3: Recording should be done promptly and accurately
Rationale 4: Recording should be done promptly and accurately
Global Rationale:
Cognitive Level:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 32
Type: MCSA
The nurse is asked to obtain informed consent for surgery that will be performed on a client the following day.
The appropriate action is
1. Explaining the procedure to the client, and having the client sign the form
2. Witnessing the signature, not whether the client understands what will occur
3. Having the client sign a blank form that the physician can fill out later
4. Having a family member talk to the patient to convince them to have the procedure
Correct Answer: 2
Rationale 1: The care provider performing the procedures is responsible for obtaining informed consent
Rationale 2: The care provider performing the procedures is responsible for obtaining informed consent
Rationale 3: The care provider performing the procedures is responsible for obtaining informed consent
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Rationale 4: The care provider performing the procedures is responsible for obtaining informed consent
Global Rationale:
Cognitive Level: Understanding
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 33
Type: MCMA
Physician and other healthcare providers write orders for procedures and medications. The nurse is responsible for
Standard Text: Select all that apply.
1. Questioning an order that the client questions
2. Carrying out an order that is dated and signed by the provider
3. Carrying out verbal orders given by the physician
4. Questioning illegible orders
5. Assuming the dosage of an unclear order
Correct Answer: 1,2,4
Rationale 1: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 2: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 3: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 4: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 5: If a client questions an order, the nurse should recheck the order before giving the medication
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 34
Type: MCMA
A 42 year-old postoperative patient reports falling in the bathroom. The incident report the nurse files needs to
include
Standard Text: Select all that apply.
1. Client name, and hospital or identification number
2. Date, time, place of incident
3. Conclusions based on clients report
4. Identify witness to the incident
5. Ask charge nurse to fill out report
Correct Answer: 1,2,4
Rationale 1: Client name, hospital or identification number, initials
Rationale 2: Client name, hospital or identification number, initials
Rationale 3: Client name, hospital or identification number, initials
Rationale 4: Client name, hospital or identification number, initials
Rationale 5: Client name, hospital or identification number, initials
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 35
Type: MCMA
A new graduate LPN is worried about a nurse who works with her. The preceptor discusses the signs of an
impaired nurse as including
Standard Text: Select all that apply.
1. Habitual tardiness
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

2. Complaints of poor-quality nursing care


3. Mood swings
4. Increased productivity
5. Frequent requests to waste narcotic doses
Correct Answer: 1,2,3,5
Rationale 1: Problems with lateness or missing work may be a sign of an impaired nurse
Rationale 2: Increasing reports or complaints of poor-quality nursing care may be a sign of an impaired nurse
Rationale 3: Emotional lability may be a sign of an impaired nurse
Rationale 4: Decreased productivity may be a sign of an impaired nurse
Rationale 5: Frequent requests to waste narcotics may be a sign of an impaired nurse
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 36
Type: MCSA
The nurse is asked to obtain informed consent for surgery that will be performed on a client the following day.
The appropriate action is
1. Explaining the procedure to the client, and having the client sign the form
2. Witnessing the signature, not whether the client understands what will occur
3. Having the client sign a blank form that the physician can fill out later
4. Having a family member talk to the patient to convince them to have the procedure
Correct Answer: 2
Rationale 1: The care provider performing the procedures is responsible for obtaining informed consent
Rationale 2: The care provider performing the procedures is responsible for obtaining informed consent
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: The care provider performing the procedures is responsible for obtaining informed consent
Rationale 4: The care provider performing the procedures is responsible for obtaining informed consent
Global Rationale:
Cognitive Level: Understanding
Client Need: Safe and Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 37
Type: MCMA
Physician and other healthcare providers write orders for procedures and medications. The nurse is responsible for
Standard Text: Select all that apply.
1. Questioning an order that the client questions
2. Carrying out an order that is dated and signed by the provider
3. Carrying out verbal orders given by the physician
4. Questioning illegible orders
5. Assuming the dosage of an unclear order
Correct Answer: 1,2,4
Rationale 1: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 2: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 3: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 4: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 5: If a client questions an order, the nurse should recheck the order before giving the medication
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome:
Question 38
Type: MCMA
A 42 year-old postoperative patient reports falling in the bathroom. The incident report the nurse files needs to
include
Standard Text: Select all that apply.
1. Client name, and hospital or identification number
2. Date, time, place of incident
3. Conclusions based on clients report
4. Identify witness to the incident
5. Ask charge nurse to fill out report
Correct Answer: 1,2,4
Rationale 1: Client name, hospital or identification number, initials
Rationale 2: Client name, hospital or identification number, initials
Rationale 3: Client name, hospital or identification number, initials
Rationale 4: Client name, hospital or identification number, initials
Rationale 5: Client name, hospital or identification number, initials
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 39
Type: MCMA
A new graduate LPN is worried about a nurse who works with her. The preceptor discusses the signs of an
impaired nurse as including
Standard Text: Select all that apply.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Habitual tardiness
2. Complaints of poor-quality nursing care
3. Mood swings
4. Increased productivity
5. Frequent requests to waste narcotic doses
Correct Answer: 1,2,3,5
Rationale 1: Problems with lateness or missing work may be a sign of an impaired nurse
Rationale 2: Increasing reports or complaints of poor-quality nursing care may be a sign of an impaired nurse
Rationale 3: Emotional lability may be a sign of an impaired nurse
Rationale 4: Decreased productivity may be a sign of an impaired nurse
Rationale 5: Frequent requests to waste narcotics may be a sign of an impaired nurse
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 40
Type: MCSA
A code of ethics for nurses
1. Includes only registered nurses in its scope
2. Outlines specifics of professional behavior
3. Guides the profession in self regulation
4. Specifies moral actions for the nurse to take
Correct Answer: 3
Rationale 1: A code of ethics for nurses includes all nurses
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: A code of ethics for nurses includes all nurses


Rationale 3: A code of ethics for nurses includes all nurses
Rationale 4: A code of ethics for nurses includes all nurses
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 41
Type: MCSA
The nursing code of ethics reminds nurses
1. To make good decisions
2. To avoid ethical dilemmas
3. Of the special responsibility they assume when caring for the sick
4. Carry out hospital policies
Correct Answer: 3
Rationale 1: The nursing code of ethics provides guidelines for professional behavior
Rationale 2: The code of ethics provides an outline of the major ethical considerations of the profession
Rationale 3: Nurses assume a special responsibility with a standard for professional actions
Rationale 4: due to the at risk populations they serve
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 42
Type: MCMA
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Nursing codes of ethics have several purposes, including


Standard Text: Select all that apply.
1. Informing the public about minimum standards that acceptable for nursing conduct
2. Outlines the major ethical considerations of the profession
3. General guidelines for nurses to follow regarding professional behavior
4. Mandates regulation
5. Provides a sign of the professions commitment to itself
Correct Answer: 1,2,3
Rationale 1: A nursing code of ethics helps the public understand minimum standards for professional conduct
Rationale 2: The nursing code of ethics assists nurses with ethical behaviors and decisions
Rationale 3: The code of ethics does not specify actions, rather it guides the nurse in order to conduct themselves
professionally
Rationale 4: The codes of ethics do not mandate regulations for any national or state association
Rationale 5: A code of ethics provides the public with a sign of the professions commitment to it
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 43
Type: MCSA
The appropriate action for the nurse who is HIV positive is to
1. Forfeit her license and stop practicing
2. Hide his or her HIV status
3. Test all patients before and after contact to be sure they are not infected
4. Avoid exposure prone procedures
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 4
Rationale 1: The HIV positive nurse is capable of practicing as long as he or she complies with OSHA standards
Rationale 2: HIV related information is confidential, and the nurse should not be dismissed solely on HIV status,
so hiding such status is not necessary
Rationale 3: Voluntary testing should be available to all. If OSHA standards are met during patient care, the risk
for transmission is minimal
Rationale 4: The HIV positive nurse should avoid procedures during which transmission of blood or body fluids
is possible, such as surgery.
Global Rationale:
Cognitive Level:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Question 44
Type: MCSA
When caring for the client in intractable pain from a terminal condition, the nurse should recall that
1. The ANAs position on assisted suicide states that it is in violation of the Code for Nurses
2. The legality of the action is the only consideration
3. Active euthanasia is legal in some jurisdictions
4. Passive euthanasia is a violation of the ANA code
Correct Answer: 1
Rationale 1: Active euthanasia and assisted suicide are in violation of the code for nurses, and can result in
criminal charges of murder
Rationale 2: The legality of the action is only one aspect for consideration. The morality of the action is
controversial in our society
Rationale 3: Active euthanasia and assisted suicide are forbidden by law and can result in criminal charges of
murder
Rationale 4: Passive euthanasia involves withdrawal of extraordinary means of life support, such as making a
client a no code, and is not a violation of the ANA code
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Understanding
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Question 45
Type: MCMA
The debate on abortion affects nurses in which of the following ways?
Standard Text: Select all that apply.
1. If it is legally permissible in the nurses state, he or she must assist with the procedure
2. Most states provide for individual physicians, nurses and institutions to refuse to assist with the procedure
3. The nurse can counsel the woman on reasons not to have the procedure
4. The nurse can counsel the woman on all aspects of the procedure
5. Nurses may have strong feelings regarding the procedure
Correct Answer: 2,4,5
Rationale 1: Most states provide for the nurse to refuse to assist if doing so violates their religious or moral
principles
Rationale 2: Refusal is optional via a conscience clause, on the grounds of religious or moral principles
Rationale 3: Nurses have no right to impose their values on a client
Rationale 4: Nurses may counsel on all aspects of the procedure, without imposing their values on a client
Rationale 5: Nurses may feel strongly about the procedure, and its ramifications. However, at the same time,
nurses have no right to impose their values on a client
Global Rationale:
Cognitive Level: Understanding
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 46
Type: MCSA
The nurse is asked to obtain informed consent for surgery that will be performed on a client the following day.
The appropriate action is
1. Explaining the procedure to the client, and having the client sign the form
2. Witnessing the signature, not whether the client understands what will occur
3. Having the client sign a blank form that the physician can fill out later
4. Having a family member talk to the patient to convince them to have the procedure
Correct Answer: 2
Rationale 1: The care provider performing the procedures is responsible for obtaining informed consent
Rationale 2: The care provider performing the procedures is responsible for obtaining informed consent
Rationale 3: The care provider performing the procedures is responsible for obtaining informed consent
Rationale 4: The care provider performing the procedures is responsible for obtaining informed consent
Global Rationale:
Cognitive Level: Understanding
Client Need: Safe and Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 47
Type: MCMA
Physician and other healthcare providers write orders for procedures and medications. The nurse is responsible for
Standard Text: Select all that apply.
1. Questioning an order that the client questions
2. Carrying out an order that is dated and signed by the provider
3. Carrying out verbal orders given by the physician
4. Questioning illegible orders
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

5. Assuming the dosage of an unclear order


Correct Answer: 1,2,4
Rationale 1: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 2: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 3: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 4: If a client questions an order, the nurse should recheck the order before giving the medication
Rationale 5: If a client questions an order, the nurse should recheck the order before giving the medication
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 48
Type: MCMA
A 42 year-old postoperative patient reports falling in the bathroom. The incident report the nurse files needs to
include
Standard Text: Select all that apply.
1. Client name, and hospital or identification number
2. Date, time, place of incident
3. Conclusions based on clients report
4. Identify witness to the incident
5. Ask charge nurse to fill out report
Correct Answer: 1,2,4
Rationale 1: Client name, hospital or identification number, initials
Rationale 2: Client name, hospital or identification number, initials
Rationale 3: Client name, hospital or identification number, initials
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: Client name, hospital or identification number, initials


Rationale 5: Client name, hospital or identification number, initials
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 49
Type: MCMA
A new graduate LPN is worried about a nurse who works with her. The preceptor discusses the signs of an
impaired nurse as including
Standard Text: Select all that apply.
1. Habitual tardiness
2. Complaints of poor-quality nursing care
3. Mood swings
4. Increased productivity
5. Frequent requests to waste narcotic doses
Correct Answer: 1,2,3,5
Rationale 1: Problems with lateness or missing work may be a sign of an impaired nurse
Rationale 2: Increasing reports or complaints of poor-quality nursing care may be a sign of an impaired nurse
Rationale 3: Emotional lability may be a sign of an impaired nurse
Rationale 4: Decreased productivity may be a sign of an impaired nurse
Rationale 5: Frequent requests to waste narcotics may be a sign of an impaired nurse
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation


Learning Outcome:
Question 50
Type: FIB
An appropriate initial action for the nurse to take when a client touches her or him inappropriately would be to
Standard Text:
Correct Answer: Take the hand and move it away, use direct eye contact and say Dont do that.
Rationale : Avoid the clients room
Global Rationale:
Cognitive Level:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome:
Question 51
Type: MCSA
Writing in the nurses notes that a physician is incompetent is an example of:
1. Slander.
2. Malpractice.
3. Libel.
4. Negligence.
Correct Answer: 3
Rationale 1: Slander is defamation by the spoken word, stating information or false words that can cause damage
to a persons reputation.
Rationale 2: Malpractice is negligence that occurred while the person was performing as a professional.
Rationale 3: Libel is defamation by means of print, either writing or pictures.
Rationale 4: Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable,
and prudent practitioner which places another person at risk for harmCognitive Level: Applying
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Negligence is misconduct or practice that is below the standard expected of an ordinary,
reasonable, and prudent practitioner which places another person at risk for harmCognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 52
Type: MCMA
In order for a case of nursing malpractice to be proven, which of the following must be proven?
Standard Text: Select all that apply.
1. Duty
2. Breach of duty
3. Causation
4. Harm
5. Negligence
Correct Answer: 1,2,3,4
Rationale 1: The nurse must have a working relationship with the client (duty).
Rationale 2: The nurse must have a working relationship with the client (duty).
Rationale 3: The nurse must have a working relationship with the client (duty).
Rationale 4: The nurse must have a working relationship with the client (duty).
Rationale 5: The nurse must have a working relationship with the client (duty).
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 53
Type: MCSA
The regulation of nursing is a function of what kind of law in the United States?
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Provincial
2. State
3. Federal
4. Contract
Correct Answer: 2
Rationale 1: Provincial law is Canadian.
Rationale 2: The regulation of nursing is a function of state law in the United States. State legislatures pass
statutes that define and regulate nursing called nurse practice acts.
Rationale 3: Federal law does not regulate nursing.
Rationale 4: Contract law affects nursing, but does not regulate nursing practice.
Global Rationale:
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 54
Type: MCMA
The nurse understands that the boundaries of client care regarding intentional torts include:
Standard Text: Select all that apply.
1. Assault.
2. Battery.
3. False imprisonment.
4. Invasion of privacy.
5. Misdemeanor.
Correct Answer: 1,2,3,4
Rationale 1: Assault can be described as an attempt or threat to touch another person unjustifiably.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: Battery is the willful touching of a person regardless of whether it causes harm.
Rationale 3: False imprisonment is the unlawful restraint or detention of another person against his wishes.
Rationale 4: Invasion of privacy is a direct wrong of a personal nature that injures the feelings of the person and
does not take into account the effect of revealed information on the standing of the person in the community.
Rationale 5: A misdemeanor is a criminal offense that is less serious than a felony.
Global Rationale:
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 55
Type: MCMA
The nurse explains the components of credentialing as including:
Standard Text: Select all that apply.
1. Licensure.
2. Registration.
3. Certification.
4. Accreditation.
5. Nurse practice act.
Correct Answer: 1,2,3,4
Rationale 1: Licensing is mandatory in in the United States to practice nursing.
Rationale 2: Licensing is mandatory in in the United States to practice nursing.
Rationale 3: Licensing is mandatory in in the United States to practice nursing.
Rationale 4: Licensing is mandatory in in the United States to practice nursing.
Rationale 5: Licensing is mandatory in in the United States to practice nursing.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Applying


Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 56
Type: MCSA
The nurse has separate, interdependent legal roles that include provider of service, citizen, and:
1. Supervisor.
2. Contractor for services.
3. Worker.
4. Floater.
Correct Answer: 2
Rationale 1: The role of supervisor is not a legal role, it is an employment role.
Rationale 2: The role of supervisor is not a legal role, it is an employment role.
Rationale 3: The role of supervisor is not a legal role, it is an employment role.
Rationale 4: The role of supervisor is not a legal role, it is an employment role.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 57
Type: MCMA
In order to be protected by a Good Samaritan act, the nurse must follow which of the following guidelines?
Standard Text: Select all that apply.
1. Limit actions to those normally considered first aid, if possible.
2. Perform only actions that she knows how to do.
3. Offer assistance but do not insist.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

4. Do not leave the scene until the injured person leaves or another qualified person takes over.
5. Do whatever needs to be done to save the injured persons life.
Correct Answer: 1,2,3,4
Rationale 1: Limiting ones actions to first aid
Rationale 2: Limiting ones actions to first aid
Rationale 3: Limiting ones actions to first aid
Rationale 4: Limiting ones actions to first aid
Rationale 5: Limiting ones actions to first aid
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 58
Type: MCSA
Which of the following actions will assist in protecting the nurse from legal action?
1. Recording client information in the chart at the end of the shift
2. Delegating as much client care as possible
3. Assuring clients that you know what is best for them
4. Asking for assistance
Correct Answer: 4
Rationale 1: Recording should be done promptly and accurately.
Rationale 2: Recording should be done promptly and accurately.
Rationale 3: Recording should be done promptly and accurately.
Rationale 4: Recording should be done promptly and accurately.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Knowledge


Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 59
Type: MCSA
The nurse is asked to obtain informed consent for surgery that will be performed on a client the following day.
The appropriate action is:
1. Explaining the procedure to the client, and having the client sign the form.
2. Witnessing the signature, not whether the client understands what will occur.
3. Having the client sign a blank form that the physician can fill out later.
4. Having a family member talk to the patient to convince him to have the procedure.
Correct Answer: 2
Rationale 1: The care provider performing the procedures is responsible for obtaining informed consent.
Rationale 2: The care provider performing the procedures is responsible for obtaining informed consent.
Rationale 3: The care provider performing the procedures is responsible for obtaining informed consent.
Rationale 4: The care provider performing the procedures is responsible for obtaining informed consent.
Global Rationale:
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 60
Type: MCMA
Physicians and other healthcare providers write orders for procedures and medications. The nurse is responsible
for:
Standard Text: Select all that apply.
1. Questioning an order that the client questions.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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2. Carrying out an order that is dated and signed by the provider.


3. Carrying out verbal orders given by the physician.
4. Questioning illegible orders.
5. Assuming the dosage of an unclear order.
Correct Answer: 1,2,4
Rationale 1: If a client questions an order, the nurse should recheck the order before giving the medication.
Rationale 2: If a client questions an order, the nurse should recheck the order before giving the medication.
Rationale 3: If a client questions an order, the nurse should recheck the order before giving the medication.
Rationale 4: If a client questions an order, the nurse should recheck the order before giving the medication.
Rationale 5: If a client questions an order, the nurse should recheck the order before giving the medication.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 61
Type: MCMA
A 42-year-old postoperative patient reports falling in the bathroom. The incident report the nurse files needs to
include:
Standard Text: Select all that apply.
1. Client name and hospital or identification number.
2. Date, time, and place of incident.
3. Conclusions based on clients report.
4. Identification of witnesses to the incident.
5. Asking the charge nurse to fill out a report.
Correct Answer: 1,2,4
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Rationale 1: Client name, hospital or identification number, initials


Rationale 2: Client name, hospital or identification number, initials
Rationale 3: Client name, hospital or identification number, initials
Rationale 4: Client name, hospital or identification number, initials
Rationale 5: Client name, hospital or identification number, initialsCognitive Level: Applying
Global Rationale:
Cognitive Level: Client name, hospital or identification number, initialsCognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 62
Type: MCMA
A new graduate LPN is worried about a nurse who works with her. The preceptor discusses the signs of an
impaired nurse as including:
Standard Text: Select all that apply.
1. Habitual tardiness.
2. Complaints of poor-quality nursing care.
3. Mood swings.
4. Increased productivity.
5. Frequent requests to waste narcotic doses.
Correct Answer: 1,2,3,5
Rationale 1: Problems with lateness or missing work can be a sign of an impaired nurse.
Rationale 2: Increasing reports or complaints of poor-quality nursing care can be a sign of an impaired nurse.
Rationale 3: Emotional lability can be a sign of an impaired nurse.
Rationale 4: Decreased productivity can be a sign of an impaired nurse.
Rationale 5: Frequent requests to waste narcotics can be a sign of an impaired nurse.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 63
Type: MCSA
A code of ethics for nurses:
1. Includes only registered nurses in its scope.
2. Outlines specifics of professional behavior.
3. Guides the profession in self-regulation.
4. Specifies moral actions for the nurse to take.
Correct Answer: 3
Rationale 1: A code of ethics for nurses includes all nurses.
Rationale 2: A code of ethics for nurses includes all nurses.
Rationale 3: A code of ethics for nurses includes all nurses.
Rationale 4: A code of ethics for nurses includes all nurses.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 64
Type: MCSA
The nursing code of ethics reminds nurses:
1. To make good decisions.
2. To avoid ethical dilemmas.
3. Of the special responsibility they assume when caring for the sick.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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4. To carry out hospital policies.


Correct Answer: 3
Rationale 1: The nursing code of ethics provides guidelines for professional behavior.
Rationale 2: The code of ethics provides an outline of the major ethical considerations of the profession.
Rationale 3: Nurses assume a special responsibility with a standard for professional actions.
Rationale 4: due to the at-risk populations they serve.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 65
Type: MCMA
Nursing codes of ethics have several purposes, including:
Standard Text: Select all that apply.
1. Informing the public about minimum standards that acceptable for nursing conduct.
2. Outlining the major ethical considerations of the profession.
3. General guidelines for nurses to follow regarding professional behavior.
4. Mandating regulation.
5. Providing a sign of the professions commitment to itself.
Correct Answer: 1,2,3
Rationale 1: A nursing code of ethics helps the public understand minimum standards for professional conduct.
Rationale 2: The nursing code of ethics assists nurses with ethical behaviors and decisions.
Rationale 3: The code of ethics does not specify actions; rather, it guides the nurse in order to conduct themselves
professionally.
Rationale 4: The codes of ethics do not mandate regulations for any national or state association.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Rationale 5: A code of ethics provides the public with a sign of the professions commitment to it.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 66
Type: MCSA
The appropriate action for the nurse who is HIV-positive is to:
1. Forfeit her license and stop practicing.
2. Hide her HIV status.
3. Test all patients before and after contact to be sure they are not infected.
4. Avoid exposure-prone procedures.
Correct Answer: 4
Rationale 1: The HIV-positive nurse is capable of practicing as long as she complies with OSHA standards.
Rationale 2: HIV-related information is confidential, and the nurse should not be dismissed solely on HIV status,
so hiding such status is not necessary.
Rationale 3: Voluntary testing should be available to all. If OSHA standards are met during patient care, the risk
for transmission is minimal.
Rationale 4: The HIV-positive nurse should avoid procedures during which transmission of blood or body fluids
is possible, such as surgery.
Global Rationale:
Cognitive Level: Synthesis
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Question 67
Type: MCSA
When caring for the client in intractable pain from a terminal condition, the nurse should recall that:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. The ANAs position on assisted suicide states that it is in violation of the code for nurses.
2. The legality of the action is the only consideration.
3. Active euthanasia is legal in some jurisdictions.
4. Passive euthanasia is a violation of the ANA code.
Correct Answer: 1
Rationale 1: Active euthanasia and assisted suicide are in violation of the code for nurses, and can result in
criminal charges of murder.
Rationale 2: The legality of the action is only one aspect for consideration. The morality of the action is
controversial in our society.
Rationale 3: Active euthanasia and assisted suicide are forbidden by law, and can result in criminal charges of
murder.
Rationale 4: Passive euthanasia involves withdrawal of extraordinary means of life support, such as making a
client a no code, and is not a violation of the ANA code.
Global Rationale:
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Question 68
Type: MCMA
The debate on abortion affects nurses in which of the following ways?
Standard Text: Select all that apply.
1. If it is legally permissible in the nurses state, he must assist with the procedure.
2. Most states provide for individual physicians, nurses, and institutions to refuse to assist with the procedure.
3. The nurse can counsel the woman on reasons not to have the procedure.
4. The nurse can counsel the woman on all aspects of the procedure.
5. Nurses might have strong feelings regarding the procedure.
Correct Answer: 2,4,5
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 1: Most states provide for the nurse to refuse to assist if doing so violates his religious or moral
principles.
Rationale 2: Refusal is optional via a conscience clause, on the grounds of religious or moral principles.
Rationale 3: Nurses have no right to impose their values on a client.
Rationale 4: Nurses may counsel on all aspects of the procedure, without imposing their values on a client.
Rationale 5: Nurses might feel strongly about the procedure, and its ramifications. However, at the same time,
nurses have no right to impose their values on a client.
Global Rationale:
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.