An adult female ambulatory care client receiving an oral anticoagulant is given
aspirin for a headache while visiting a neighbor, who is a nurse. The client
subsequently has a bleeding episode because of a drug interaction. The legal
nurse consultant interprets that which necessary elements of malpractice are
missing from this case? Select all that apply.
1. Breech of duty
2. Duty owed
3. Injury experienced
4. Causation between nurse's action and injury
5. Intent to cause harm or injury
Answer: 2, 5
Rationale: There was no nurse-client relationship because the nurse was acting
as a neighbor and not in an employment capacity. Thus, there can be no duty
owed. Intent is not a necessary element of malpractice, because malpractice can
occur because of unintended actions as well. There was no breach of duty
because there was no official nurse-client relationship, which accompanies an
employment situation. There was injury experiences because of this event. The
bleeding was caused by the interaction of the aspirin with the anticoagulant.
Cognitive Level: Analyzing
Client Need: Management of Care
Integrated Process: Nursing Process: Evaluation
Content Area: Fundamentals
Strategy: Use the process of elimination. The wording of the question indicates
more than one option is correct, and the focus is on necessary elements that must
be present. First eliminate the intent to cause harm or injury, since this is not
necessary to a charge of malpractice. Next note that there is no duty owed, and
because of this, there can be no breach of duty, to choose these two options as
the necessary missing elements.
,After receiving the inter shift report, the registered nurse (RN) has many tasks to
complete during the next 12 hours. Which tasks would the nurse delegate to an
unlicensed person (UAP)? Select all that apply.
1. Flushing a nasogastric tube on a client who has had a colectomy
2. Irrigating a clogged urinary catheter on an older adult client
3. Rechecking vital signs on a 30-year-old client with a BP of 100/60
4. Changing a dressing on a client with an infected diabetic foot ulcer
5. Measuring and recording hourly ruin output for a client who underwent
nephrectomy
Answer:
Rationale:
Cognitive Level:
Client Need:
Integrated Process:
Content Area:
Strategy:
The charge nurse on the night shift reports that the narcotic count is incorrect.
The nurse has spoken to the responsible staff nurse and believes that substance
abuse by the nurse is the cause. If substance abuse proves to be the cause of the
incorrect count, what is the most appropriate next step?
1. Recount the narcotics with the staff nurse and take disciplinary action
2. Ask the staff nurse to leave the unit and report the incident to the American
Nurses Association
3. Complete an incident report and report findings to the pharmacy and nursing
administration
4. Submit the findings to the Council on Nursing Practice
Answer:
Rationale:
Cognitive Level:
Client Need:
Integrated Process:
Content Area:
Strategy:
, A client asks why a diagnostic test has been ordered and the nurse replies, "I'm
unsure but will find out for you." When the nurse later returns and provides an
explanation, the nurse is acting under which principle?
1. Nonmaleficence
2. Veracity
3. Beneficence
4. Fidelity
Answer: 4
Rationale: Fidelity means being faithful to agreements and promises. This nurse
is acting on the client's behalf to obtain needed information and report it back to
the client. Nonmaleficence is the duty to do no harm. Veracity refers to telling
the truth for example, not lying to a client about a serious prognosis.
Beneficence means doing good, such as by implementing actions (e.g. keeping a
salt shaker out of sight) that benefit a client (heart condition requiring sodium-
restricted diet).
Cognitive Level: Understanding
Client Need: Management of Care
Integrated Process: Nursing Process: Implementation
Content Area: Fundamentals
Strategy: Use the process of elimination. The correct answer is the one that
matches the description in the stem; that is, the nurse made a promise to a client
and kept it, which constitutes fidelity.
A client is experiencing respiratory distress. Respirations are 32 breaths/min and
shallow. The client is positioned in an orthopneic position, with a heart rate of
118/min and a blood pressure of 90/40 mmHg. The client is pale and confused.
Which task should the nurse delegate to the charge nurse?
1. Head-to-toe assessment
2. Placement of a second IV site
3. Application of oxygen
4. Overhead page the respiratory therapist (RT)
Answer:
Rationale:
Cognitive Level:
Client Need:
Integrated Process:
Content Area:
Strategy:
aspirin for a headache while visiting a neighbor, who is a nurse. The client
subsequently has a bleeding episode because of a drug interaction. The legal
nurse consultant interprets that which necessary elements of malpractice are
missing from this case? Select all that apply.
1. Breech of duty
2. Duty owed
3. Injury experienced
4. Causation between nurse's action and injury
5. Intent to cause harm or injury
Answer: 2, 5
Rationale: There was no nurse-client relationship because the nurse was acting
as a neighbor and not in an employment capacity. Thus, there can be no duty
owed. Intent is not a necessary element of malpractice, because malpractice can
occur because of unintended actions as well. There was no breach of duty
because there was no official nurse-client relationship, which accompanies an
employment situation. There was injury experiences because of this event. The
bleeding was caused by the interaction of the aspirin with the anticoagulant.
Cognitive Level: Analyzing
Client Need: Management of Care
Integrated Process: Nursing Process: Evaluation
Content Area: Fundamentals
Strategy: Use the process of elimination. The wording of the question indicates
more than one option is correct, and the focus is on necessary elements that must
be present. First eliminate the intent to cause harm or injury, since this is not
necessary to a charge of malpractice. Next note that there is no duty owed, and
because of this, there can be no breach of duty, to choose these two options as
the necessary missing elements.
,After receiving the inter shift report, the registered nurse (RN) has many tasks to
complete during the next 12 hours. Which tasks would the nurse delegate to an
unlicensed person (UAP)? Select all that apply.
1. Flushing a nasogastric tube on a client who has had a colectomy
2. Irrigating a clogged urinary catheter on an older adult client
3. Rechecking vital signs on a 30-year-old client with a BP of 100/60
4. Changing a dressing on a client with an infected diabetic foot ulcer
5. Measuring and recording hourly ruin output for a client who underwent
nephrectomy
Answer:
Rationale:
Cognitive Level:
Client Need:
Integrated Process:
Content Area:
Strategy:
The charge nurse on the night shift reports that the narcotic count is incorrect.
The nurse has spoken to the responsible staff nurse and believes that substance
abuse by the nurse is the cause. If substance abuse proves to be the cause of the
incorrect count, what is the most appropriate next step?
1. Recount the narcotics with the staff nurse and take disciplinary action
2. Ask the staff nurse to leave the unit and report the incident to the American
Nurses Association
3. Complete an incident report and report findings to the pharmacy and nursing
administration
4. Submit the findings to the Council on Nursing Practice
Answer:
Rationale:
Cognitive Level:
Client Need:
Integrated Process:
Content Area:
Strategy:
, A client asks why a diagnostic test has been ordered and the nurse replies, "I'm
unsure but will find out for you." When the nurse later returns and provides an
explanation, the nurse is acting under which principle?
1. Nonmaleficence
2. Veracity
3. Beneficence
4. Fidelity
Answer: 4
Rationale: Fidelity means being faithful to agreements and promises. This nurse
is acting on the client's behalf to obtain needed information and report it back to
the client. Nonmaleficence is the duty to do no harm. Veracity refers to telling
the truth for example, not lying to a client about a serious prognosis.
Beneficence means doing good, such as by implementing actions (e.g. keeping a
salt shaker out of sight) that benefit a client (heart condition requiring sodium-
restricted diet).
Cognitive Level: Understanding
Client Need: Management of Care
Integrated Process: Nursing Process: Implementation
Content Area: Fundamentals
Strategy: Use the process of elimination. The correct answer is the one that
matches the description in the stem; that is, the nurse made a promise to a client
and kept it, which constitutes fidelity.
A client is experiencing respiratory distress. Respirations are 32 breaths/min and
shallow. The client is positioned in an orthopneic position, with a heart rate of
118/min and a blood pressure of 90/40 mmHg. The client is pale and confused.
Which task should the nurse delegate to the charge nurse?
1. Head-to-toe assessment
2. Placement of a second IV site
3. Application of oxygen
4. Overhead page the respiratory therapist (RT)
Answer:
Rationale:
Cognitive Level:
Client Need:
Integrated Process:
Content Area:
Strategy:
