1.

After a patient's primary care physician makes rounds, the nurse

notices that the physician wrote an order for a medication that is
triple the normal dose. What should the nurse do?
a) Call the pharmacy to see if the dosage is safe
b) Ask the nurse supervisor for advice
c) Administer the medication as ordered
d) Contact the physician immediately

Answer: D

Hint : Nurses should know about the medications they administer.

The nurse should call the physician who wrote the order as soon as
possible to clarify the order. Administering the medication is incorrect
because the nurse should know the dose is outside the normal range. A
pharmacist may be helpful, but cannot change the order. Giving the
medication could cause harm to the patient, and the nurse could be
liable.

2. Which statement is true regarding medical legality?

a) Consent for medical treatment can be given by a minor with a

sexually transmitted disease (STD).
b) A nurse who becomes ill and leaves during a shift is not
abandoning patients if the supervisor is notified.
c) A second trimester abortion may be obtained without state
involvement.
d) Student nurses cannot be sued for malpractice while in a clinical
class setting.

Answer: A

Hint :HIPAA allows for "the individual" to seek treatment.

The HIPAA Privacy Rule allows for treatment of an STD infection

without parental consent. The client is “advised” to contact sexual
partners but is not “required” to give names. After age 13, permission
from parents is not needed, based upon current privacy laws. A minor
is considered "the individual" who can consent for STD treatment.
Each state has regulations regarding the stage of pregnancy when a
woman can legally obtain an abortion. Student nurses can be held
liable for their actions. Leaving a patient without care is a form of
negligence.

3. The following clients arrive for their appointments at the diabetic

clinic. Who should the nurse see first?

a) A type 1 diabetes client who feels weak but is eating a simple-

carb snack.
b) A type 2 diabetes client who will receive education about her
diet.
c) A type 1 diabetes client who needs a dressing change for his
foot ulcer.
d) A type 2 diabetes client who presents with a headache and
a fruity odor on his breath.

Answer: D

Hint : DKA can be life-threatening.

The client with a headache and fruity odor to breath shows signs of
entering diabetic ketoacidosis (DKA) and needs to be assessed
immediately. The type 1 client with possible low blood sugar is
already eating a snack and should be seen second.

4. The nurse can safely assign which task to an unlicensed assistive

personnel (UAP) for a patient who is stable after a myocardial
infarction?

a) Teach the patient about a heart-healthy diet.

b) Answer the family's questions about aftercare.
c) Report any unusual lung sounds.
d) Measure and record intake and output.

Answer: D

Hint : UAP cannot assess or educate.

UAP responsibilities are restricted to performing basic nursing tasks,

such as measuring I&O, vital signs, and weight. They provide direct
patient care, including bathing, feeding, and toileting. The licensed
nurse is responsible for assessment and education.
5. When preparing a chart before transporting a patient to surgery,
which document is NOT necessary?

a) Anesthesiology record
b) Operative consent
c) History & Physical
d) Lab test results

Answer: A

Anesthesiology record

The anesthesiologist's note and record is not available until the

surgery is complete. The other documents should accompany the
patient to surgery.

Hint : This document has not yet been created.

6. A client reports for same-day surgery wearing expensive jewelry.

What should the nurse tell the client?

a) "We keep all expensive items in the narcotic box, so no one will
take them."
b) "We'll put the jewelry in an envelope. We will both sign it,
and put it in our safe."
c) "We'll ask the supervisor to hold your jewelry until you are in the
recovery room."
d) "We will tape the jewelry to you so it will remain secure during
surgery."

Answer: B

Hint : Both client and nurse should witness the disposition of the
jewelry.

To ensure safety of valuables while a client is having a procedure, the

nurse should list the items on an envelope before sealing it. Then the
client and the nurse both sign before placing the envelope in the safe.
7. A nurse notices a discrepancy (ketidaksamaan, perselisihan,
perbezaan, ikhtilaf selisih) in the medication records for a patient
who has orders for large doses of narcotics for pain relief. What
should the nurse do first?

a) Notify the local police and narcotic division

b) Notify the hospital's legal department
c) Notify the pharmacy technician
d) Notify the unit's nursing supervisor

Answer: D

Hint : The person with oversight of the unit should be notified.

Every health care facility that stores and administers controlled

substances must have strict procedures for how to control inventory.
Discrepancies must be accounted for in a timely manner.
Documentation for loss/breakage/change in orders is essential. If the
narcotic count is not accurate, the nurse should contact the nursing
supervisor, who has oversight of the unit.

8. If a patient cannot read or write, the nurse can read the consent
form in front of two witnesses. What else should the nurse do?

a) Ask the hospital lawyer to assist with the consent

b) Ask the patient to make an "X" as a signature
c) Allow a family member to sign the consent form
d) Allow the Risk Management Supervisor to sign the consent

Answer: B

Hint The patient must sign the consent form.

The nurse can read the consent form in front of two witnesses, and
the patient can sign in their presence. The patient must sign for
himself, unless the patient is a minor or not of sound mind. The nurse
should never sign a consent form for a patient.
9. A small plane carrying the football team from the local university
crashes and survivors are being transported to the hospital. Four
team members died in the crash. Before the survivors reach the
hospital, what should the nurse anticipate being asked to do?

a) Call the nearest crisis response team

b) Call the hospital's volunteer office
c) Alert the local news station
d) Notify the university of the crash

Answer: B

Hint: Support by experienced people is essential.

After a traumatic event, there will be a great need for support from
disaster and crisis specialists. The survivors, families of the deceased
team members, fellow students, and the community will need
empathy and counseling. News media usually monitor emergency
radio, so they will already be aware. Volunteers may be helpful, but
are not experts in assisting with disasters. The university will receive
information from other sources.

10. An hour after a surgical procedure, a male client who received a

epidural anesthesia requests to get up to go to the bathroom. He still
has an IV infusing and is being assessed every 15 minutes. What is
the nurse's best response to maintain client safety?

a) "Can you sit at the edge of the bed for a few minutes, to see
how you feel?"
b) "Let me get the nursing aide to help you, since it's your first time
getting up."
c) "Okay, first let's see how well you can stand and bear
weight. Then we'll decide."
d) "It would be better if you waited until the 15 minute
assessments are complete."

Answer: C

Hint : Balance is most important.

Before allowing the client to get up, the nurse needs to know if he can
bear weight and keep his balance. Unless he is unstable, asking him
to wait is not appropriate. Sitting at the edge of the bed can avoid
orthostatic hypotension, but the nurse can't determine if the client can
ambulate. Once the client demonstrates that he can bear weight,
assisting him to the bathroom for the first time is a good safety
measure.

11. When caring for a patient diagnosed with viral hepatitis, the
healthcare provider experiences a needlestick with a contaminated
needle. Which of the following actions should the healthcare provider
do first?

a) Put the needle in a biohazard bag for testing.

b) Wash the area thoroughly with soap and water.
c) Make an appointment with the infection control department.
d) Report to the emergency department.

Answer: B

Hint: The initial action is aimed at reducing the possibility of infection.

The puncture site and skin should be washed thoroughly with soap
and water. Then the healthcare provider will follow the next steps in
the facility protocol. The healthcare provider will follow the facility-
specific protocol for when a needlestick occurs. Typically, after
reporting the incident to your supervisor, you will be directed to seek
immediate treatment.

12. Nurses agree to be advocates (penganjur, peguam,

memperakukan, menganjurkan ) for their patients. Practice of
advocacy calls for the nurse to

a) Document all clinical changes in the medical record every two

hours
b) Apply the law to the patient's clinical condition
c) Assess the patient's perspective and explain it when
necessary
d) Seek out the nursing supervisor to resolve conflicts

Answer: C
Hint: An advocate speaks out for another person's well-being.

Nurses always strive to assess and understand their patients. When

they are able to identify a patient's personal values and then
accurately describe these values of the client and defend the patient’s
point of view, they can be a successful advocate.

13. Which of the following drugs should not be refrigerated?

a) Epoetin alfa IV (Epogen)

b) Opened (in-use) Humulin N injection
c) Nadolol (Corgard)
d) Ampicillin Oral Suspension

Answer: C

Hint: The cardiac drug is not refrigerated.

Nadolol (Corgard) is a beta-blocker used to treat hypertension and

chest pain. It is stored tightly closed at room temperature between 59
to 86 ºF (15 and 30 ºC) away from heat, moisture, and light. Humulin
N is a form of insulin. After being opened, it is stored in the
refrigerator or at room temperature below 86 ºF . Humulin N must be
discarded 31 days after opening. Ampicillin is a penicillin antibiotic.
The liquid suspension form should be stored in the refrigerator for up
to 7 days. Epoetin alfa IV is used for patients undergoing
chemotherapy or with anemia from serious chronic diseases. It is
stored in the refrigerator and should be protected from light.

14. A nurse in the Neonatal ICU administers adult-strength digitalis

(Digoxin, Lanoxin) to a 3-pound infant. As a result, the neonate
experiences permanent heart and brain damage. The nurse can be
charged with

a) Tort
b) Assault
c) Malpractice
d) Negligence

Answer: C
Hint : When a nurse fails to take reasonable steps to prevent loss,
suffering, or injury to a patient, the nurse has neglected duty.

The nurse could be charged with malpractice, which is failing to

perform, or performing an act that causes harm to the client. Giving
the infant an overdose, even if accidental, is malpractice.

Negligence is failing to perform the proper standard of care for a

patient; a tort is a wrongful act committed on the patient or the
patient's belongings; and assault is a violent physical or verbal attack.

15. After instructing a client on how to provide a urine sample for a

stat urinalysis, the nurse returns two hour later to find the specimen in
the client's bathroom. The nurse should

a) Initiate an incident report for the delay.

b) Refrigerate the sample before sending to the lab.
c) Immediately send the sample to the laboratory.
d) Discard the urine and obtain a fresh specimen.

Answer: D

Hint : The time frame for a specimen is short.

A urine sample that has been at room temperature for more than 1
hour is not acceptable. The urine will become alkaline and bacteria
can begin to grow, leading to inaccurate results. If a sample cannot
be immediately delivered to the laboratory, it should be refrigerated.

16. The legal document that lists the medical procedures and
treatments a person will refuse if unable to make decisions is the

a) Advance Directive
b) Power of Attorney
c) Informed Consent
d) Patient Bill of Rights

Answer: A

Hint : This document is also called a Medical Directive.

An advance directive is a legal document that makes provision for

future health care decisions if the person is unable to do so. It can
include a Living Will and durable Power of Attorney for Health Care.
 17. Which patient has the highest risk of falling?

a) A 75-year old female with episodes of syncope (pitam).

b) A 36-year old female with a fractured tibia.
c) A 63-year old male with angina pectoris.
d) A 22-year old male with 3 fractured ribs and right arm in a cast.

Answer: A

Hint : Age can increase risk of falling.

Because of age and unexpected syncope, the 75-year old female is

at the greatest risk of falling. The nurse should observe the patient's
balance and gait; the patient may require assistance when
ambulating, even when going to the bathroom.

18. Before touching a client who is crying, to offer comfort, the nurse
should consider

a) whether the client's family should be notified

b) whether the client has been sad recently
c) the client’s recent vital signs
d) the client’s cultural background

Answer: D

hint : Sometimes touch is prohibited(dilarang).

While Western culture uses therapeutic touch as a way to offer

support or comfort, other religions or cultures see it as a violation of
privacy. For example, Asians or Muslims do not welcome touch by
strangers or by the opposite gender. When in doubt, ask for
permission or be conservative in your approach.

19. When caring for a patient with Meniere's disease, which is the
most appropriate safety consideration?

a) Assist the patient to and from the bathroom.

b) Maintain contact isolation measures.
 c) Raise the side rails on the patient's bed.
d) Restrict caffeine intake after breakfast.

Answer: A

Hint: Unexpected dizziness (pening) can lead to a fall.

Meniere's disease is a disorder of the inner ear. It causes sudden

vertigo, tinnitus, and progressive loss of hearing. Due to
unpredictable episodes of dizziness, the patient should be
accompanied when ambulating. Raising siderails is considered a form
of restraint and requires a doctor's order.