legal
A practical nursing student is discussing a client's diagnosis with friends in a hospital cafeteria. A legal principle has been violated.
What is Confidentiality?
Nurses are legally and ethically required to protect client privacy. Discussing client information in public places violates confidentiality and HIPAA regulations.
A. Beneficence
B. Confidentiality
C. Veracity
D. Fidelity
Legal Documentation (Select All That Apply)
Documentation practices that are legally appropriate. Select all that apply.
A. Chart immediately after care is provided
B. Use approved abbreviations only
C. Leave blank spaces in documentation
D. Record objective observations
E. Document care that was not performed
F. Correct errors according to agency policy
Nursing action best demonstrates the ethical principle of beneficence.
Performing frequent repositioning to prevent skin breakdown.
Rationale:
Beneficence means doing good and promoting the well-being of the client.
A client states, "I was just diagnosed with diabetes and I feel overwhelmed." Therapeutic response.
A. "Everything will be fine." B. "Why are you feeling overwhelmed?" C. "Tell me more about what concerns you most." D. "You should focus on the positive aspects."
C. What is "Tell me more about what concerns you most."
Rationale:
This response encourages the client to express feelings and concerns. It is an open-ended statement that promotes therapeutic communication.
A nurse is communicating with a client who is hearing impaired.
Select all that apply.
A. Face the client when speaking. B. Speak clearly and at a normal pace. C. Cover your mouth while talking. D. Minimize background noise. E. Verify understanding.
✅ A
✅ B
✅ D
✅ E
Rationale:
These strategies facilitate effective communication with hearing-impaired clients.
The nurse administers a medication at 0800 but forgets to document it until 1100. The correct procedure.
What is make a late entry and document the actual administration time?
Rationale: Documentation should always be accurate. Late entries should be identified as such while recording the actual date and time the care was provided.
B. Ask another nurse to document it
C. Make a late entry and document the actual administration time
D. Do not document the medication
A client has a valid advance directive stating "Do Not Resuscitate" (DNR). The client becomes pulseless. Action.
What is follow the DNR order and agency policy?
Rationale: A valid DNR order must be honored. The nurse should follow agency policy and legal requirements regarding end-of-life care.
The nurse notices a medication dosage that appears unusually high. Action
B. Hold the medication and clarify the order.
Rationale:
Nonmaleficence means avoiding harm to the client. Questioning potentially unsafe orders protects the client.
Statements indicate culturally competent nursing care.
A. "I should ask clients about cultural practices that may affect care." B. "Everyone should receive the same care regardless of culture." C. "I should avoid making assumptions about beliefs." D. "Cultural preferences should be incorporated into care planning when possible." E. "My cultural beliefs are the most appropriate guide for client care."
What is
✅ A
✅ C
✅ D
Rationale:
Cultural competence involves assessment, respect, and individualized care.
A client refuses a blood transfusion due to religious beliefs.
A. "You must accept the treatment." B. "Tell me more about your beliefs and concerns." C. "Your family should convince you." D. Administer the transfusion as ordered.
What is "Tell me more about your beliefs and concerns."
Rationale:
The nurse should respect cultural and religious beliefs while assessing understanding and concerns.
The nurse is preparing a client for surgery. The client states, "I don't understand what the doctor said about the procedure." The nurse follows up by
What is Notify the healthcare provider?
Rationale: The provider performing the procedure is responsible for obtaining informed consent and answering questions. The nurse may witness the signature but does not provide the detailed explanation.
A client falls while walking to the bathroom. Which statement by the nurse is correct?
Complete an incident report and document the facts in the medical record
Rationale: Incident reports are used for risk management and quality improvement. The factual event should also be documented in the client's medical record.
Which actions demonstrate ethical nursing practice? Select all that apply.
A. Protecting confidential information
B. Advocating for client wishes
C. Respecting cultural beliefs
D. Discussing client information in public areas
E. Reporting unsafe practices
Ethical nursing practice includes confidentiality, advocacy, cultural sensitivity, and client safety.
All except D
A client states, "I don't think I can go through this treatment." priority response
A. "You must continue treatment." B. "What concerns do you have about the treatment?" C. "Many people feel that way." D. "Your provider knows what is best."
✅ B. "What concerns do you have about the treatment?"
Rationale:
This response explores the client's feelings and concerns while promoting open communication.
The nurse uses silence after a client receives bad news.
Purpose
A. To avoid answering questions B. To give the client time to process feelings C. To end the conversation D. To show disapproval
What is B. To give the client time to process feelings
Rationale:
Silence is often therapeutic and encourages reflection and expression.
A nurse forgets to raise the side rails after administering a sedative. The client falls and fractures a hip. Term
What is Negligence?
Rationale: Negligence occurs when a nurse fails to provide the standard of care, resulting in harm to the client.
A competent adult client refuses a prescribed blood transfusion due to religious beliefs. Action
Notify the provider and support the client's decision.
Rationale:
Autonomy is the right of a competent client to make healthcare decisions. The nurse should respect the client's wishes and inform the provider.
Which client rights should the nurse protect? Select all that apply.
A. Right to privacy
B. Right to refuse treatment
C. Right to informed consent
D. Right to access medical records
E. Right to receive unnecessary treatments
All except E
Clients have these legal and ethical rights. They do not have a right to demand unnecessary treatment.
nurse caring for a client from a culture that values more personal space notices the client moving away during conversation.
A. Move closer. B. Maintain the client's preferred distance. C. Touch the client to gain attention. D. Ignore the behavior.
What is B. Maintain the client's preferred distance.
Rationale:
Respecting cultural preferences related to personal space promotes trust and comfort.
A client says, "In my culture, family members make healthcare decisions."
Action by nurse
A. Inform the client that healthcare is an individual decision. B. Assess the client's preferences regarding decision-making. C. Exclude family from discussions. D. Report the family involvement.
What is B.
B. Assess the client's preferences regarding decision-making.
Rationale:
The nurse should assess and respect culturally influenced decision-making practices whenever possible.
Nursing action that is considered assault.
What is threatening to restrain a client if they get out of bed?
Rationale: Assault is making a threat that causes the client to fear harmful or offensive contact.
A client is scheduled for surgery and states, "I don't really understand what the procedure involves." Action
Notify the provider that additional teaching is needed.
Rationale:
The provider is responsible for obtaining informed consent. The nurse advocates for the client by ensuring understanding before consent is signed.
The nurse enters a room and hears a healthcare provider discussing another client's health information where visitors can hear. What should the nurse do first?
A. Report the provider to administration.
B. Ignore the situation.
C. Ask the provider to continue the conversation in a private area.
D. Discuss the issue with coworkers.
C.
The priority is immediately protecting client confidentiality.
nontherapeutic statement
A. "Tell me more about that." B. "How are you feeling today?" C. "You should not worry so much." D. "What would help you feel supported?"
What is C. "You should not worry so much."
Rationale:
This minimizes the client's feelings and discourages communication.
A nurse is caring for an older adult client from a different cultural background. The client nods during teaching about medications but is later unable to explain the instructions.
Action
A. Repeat the information louder. B. Assume the client understands because they nodded. C. Use the teach-back method to assess understanding. D. Ask a family member to explain.
C. Use the teach-back method to assess understanding.
Rationale:
Teach-back verifies understanding and helps identify communication barriers regardless of culture or language.