1. A nurse is caring for a patient with chronic heart failure who is very ill. The patient has a
"no code" order. The patient goes into ventricular fibrillation and the nurse defibrillates
the patient. The nurse states she was unaware of the "no code" order. What part of the
nursing process did the nurse fail to perform?
A. Planning
B. Evaluation
C. Assessment
B. Implementation
2. On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The
nurse does not want to "bother the physician this early." During the change-of-shift
report, the patient develops ventricular tachycardia and has to be resuscitated. What part
of the nursing process did the nurse fail to perform?
A. Evaluation
B. Implementation
C. Assessment
D. Planning
3. A patient in the critical care unit has an order to be transported off the unit for a
diagnostic procedure. The nurse fails to ensure that the patient is properly monitored
during transport, and the patient experiences a cardiac arrest. Which of the following
actions did the nurse fail to adequately perform?
A. Make the proper nursing diagnosis.
B. Assess and analyze the level of care needed by the patient.
C. Act as a patient advocate to postpone the examination.
D. Communicate findings in a timely manner.
4. The nurse fails to record a set of vital signs on a blood transfusion report, which is against
hospital policy. The patient does not sustain any damage as a result. Can the nurse be
charged with malpractice in this case?
A. No. Documentation is not part of the duty of nurse.
B. Yes. Even though there were no damages, the nurse failed to follow hospital protocol.
C. No. There were no damages associated with failure to document
D. Yes. Failure to document always results in negligence.
,5. A bnpatient bnwith bnmetastatic bncancer bntells bnthe bnnurse, bn“I bnam bntired bnand bndo bnnot bnwant bnto
bnbe bnput bnon bna bnbreathing bnmachine.” bnThe bnpatient’s bnout-of-town bnson bnwants bn“everything
bndone bnfor bnmy
mother” bnwhen bnhis bnmother bnlater bndevelops bnrespiratory bndistress. bnWhich bnethical bnprinciples
bnare bninvolved bnin bnthis bndilemma? bn(Select bnall bnthat bnapply.)
A. Beneficence b n
B. Nonmaleficence
C. Autonomy
D. Justice
E. Paternalism
6. The bnnurse bnis bnconcerned bnthat bnthe bnphysician bnis bnignoring bnthe bnwishes bnof bnthe bnpatient
bnand bnfamily bnin bnthe bncare bnof bna bnpatient. bnThe bnnurse bnshould bntake bnthese bnconcerns bnto:
bn(Select bnall bnthat bnapply.)
A. The bnhospital bnethics bncommittee
B. The bnANA bn(American bnNurses bnAssociation)
C. The bnnursing bnsupervisor
D. The bnnursing bnethics bncommittee
E. he bnpolicy bnand bnprocedure bncommittee
7. The bnnurse bnobserves bna bncoworker bndiverting bnnarcotics bnby bnadministering bnnormal
bnsaline bnto bna bnpatient bnin bnpain. bnBy bnnot bnreporting bnthis bnobservation, bnthe bnnurse bnis bnin
bnviolation bnof bnwhat bnethical bnprinciple bnconcerning bnthe bnpatients bnunder bnthe bncare bnof bnthe
bnimpaired bnnurse?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Veracity
8. The bnfamily bnof bna bnpatient bnwho bnis bnreceiving bnmechanical bnventilation bnfor bnrespiratory
bndistress bnassociated bnwith bnan bninoperable bnbrain bntumor bnasks bnthat bnthe bnpatient bnbe
bnextubated bnto bn"allow bnnatural bndeath" bnto bnoccur. bnThis bnis bnan bnexample bnof bnwhat
bnsituation?
A. Withdrawing bntreatment
B. Rationing bncare
C. A bncriminal bnact
D. Withholding bntreatment
9. A bnnurse bnhas bnbeen bnhaving bndifficulty bnsleeping bnsince bnthe bndeath bnof bna bnpatient bnwho
bnhad bna bnstressful bnfamily bnsituation bninvolving bna bnDNR bn(do bnnot bnresuscitate) bnorder. bnShe
bnis bnarguing bnwith bnher bnhusband bnand bncoworker bnand bnis bncomplaining bnabout bnworking
bnconditions. bnThe bnnurse's bnsymptoms bncould bnbe bnsigns bnof bnwhat bnproblem?
A. Moral bndistress
B. Moral bnconfusion
C. Immoral bndistress
D. Change bnfatigue
, 10. Where bnshould bna bnnurse bnplace bnthe bnstethoscope bnwhen bnauscultating bnheart bnsounds?
Select bnall bnthat bnapply
A. First bnintercostal bnspace bnleft bnof bnthe bnsternum bnto bnhear bnsounds bnfrom bnthe bnpulmonic bnvalve bnarea.
B. Fourth bnintercostal bnspace bnto bnthe bnleft bnof bnthe bnsternum bnto bnhear bnsounds bnfrom bnthe
bntricuspid bnarea.
C. Second bnintercostal bnspace bnto bnthe bnright bnof bnthe bnsternum bnto bnhear bnsounds bnfrom bnthe
bnaortic bnvalve bnarea.
D. Fifth bnintercostal bnspace bnleft bnside bnof bnsternum bnto bnhear bnsounds bnfrom bnthe bnmitral bnarea.
E. Apex bnof bnthe bnheart bnto bnhear bnthe bnloudest bn2nd bnheart bnsound bn(S2).
11. A bnclient bnreceiving bn50 bnmL/hr bnof bnenteral bnfeedings bnhas bna bngastric bnresidual bnvolume bnof
bn200 bnmL bnand bnis bnreporting bnnausea. bnWhat bnis bnthe bnappropriate bnnursing bnintervention?
1. Stop bnthe bnfeeding bnand bnassess bngastric bnresidual bnvolume bnin bn1 bnhour.
2. Reduce bnthe bninfusion bnrate bnto bn25 bnmL/ bnhour bnand bnreevaluate bnresidual bnvolume bnin bn4
bnhours.
3. Change bnthe bnfeeding bnschedule bnfrom bncontinuous bnto bnintermittent bndelivery.
4. Discard bnthe bn200 bnmL bnand bncontinue bnthe bnfeedings bnat bnthe bnsame bnrate.
12. A bnclient bnstates, bn"I bnreally bndo bnnot bnwant bnto bngo bnthrough bnopen bnheart bnsurgery. bnI bnhave bntold
bnmy
children bnthis, bnbut bnthey bnstill bnwant bnme bnto bngo bnthrough bnwith bnthe bnsurgery. bnI bndon’t bnknow
bnwhat bnto bndo." bnWhat bnis bnthe bnbest bnresponse bnfor bnthe bnnurse bnas bnclient bnadvocate?
1. Your bnchildren bnare bncorrect. bnThe bnopen-heart bnsurgery bnis bnthe bnbest bnthing bnfor bnyour bnhealth.
2. You bnfeel bnas bnif bnyour bnchildren bnare bnnot bnaddressing bnyour bnconcerns. bnYou bnand bnyour bnfamily
bnwill bnneed bnto bnresolve bnthis bnbefore bn you bngo bnto bnsurgery.
3. I bncan bncontact bnyour bnprimary bnhealthcare bnprovider bnso bnthat bnyou bncan bndiscuss bnyour bnconcerns
bnregarding bnopen bnheart bnsurgery.
4. You bnhave bnsome bngenuine bnconcerns bnabout bnthe bnopen-heart bnsurgery, bnand bnyou bnfeel
bnas bnif bnyour bnchildren bnare bnnot bnaddressing bnyour bnconcerns.
13. The bnnurse bnis bncaring bnfor bna bnclient bnwith bna bnfibula bnfracture. bnThe bnprimary bnhealthcare
bnprovider bnmakes bnrounds bnand bnwrites bnprescriptions. bnWhat bnis bnthe bnnurse's bnbest
bnaction?
1. Check bnthe bnprescription bnprior bnto bnsending bnit bnto bnthe bnpharmacy.
2. Clarify bnthe bnprescription bnwith bnthe bnprimary bnhealthcare bnprovider.
3. Notify bnthe bnpharmacy bnthat bnthe bnprescription bnis bnneeded bnimmediately.
4. Gather bnthe bnsupplies bnneeded bnfor bnan bninjection.
14. When bnthe bnsurgical bntransport bnteam bnarrives bnto bntake bna bnclient bnto bnthe bnoperating bnroom,
bnthe bnclient bnis bnsitting bnin bna bnchair bnin bnthe bnroom. bnWhat bnis bnthe bnbest bnway bnfor bnthe
bnnurse bnto bnget bnthe bnclient bnonto bnthe bntransport bnlitter?
1. Using bna bnfoot bnstool, bnassist bnclient bnto bnstep bnup bnand bncrawl bnonto bnlitter.
2. Have bnclient bnreturn bnto bnbed bnand bnutilize bnslide bnboard bnto bntransfer bnto bnlitter.
3. With bnfeet bnplaced bnapart, bngrasp bnclient bnaround bnwaist bnand bnlift bnonto bnlitter.
4. Put bnHoyer bnpad bnunder bnclient, bnusing bnLift bnto bnmove bnclient bnfrom bnchair bnto bnlitter.
15. Which bnaction bnby bna bnnurse bnwould bnindicate bnthat bnthis bnnurse bnis bnfollowing bnstandard
bnprecautions?
"no code" order. The patient goes into ventricular fibrillation and the nurse defibrillates
the patient. The nurse states she was unaware of the "no code" order. What part of the
nursing process did the nurse fail to perform?
A. Planning
B. Evaluation
C. Assessment
B. Implementation
2. On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The
nurse does not want to "bother the physician this early." During the change-of-shift
report, the patient develops ventricular tachycardia and has to be resuscitated. What part
of the nursing process did the nurse fail to perform?
A. Evaluation
B. Implementation
C. Assessment
D. Planning
3. A patient in the critical care unit has an order to be transported off the unit for a
diagnostic procedure. The nurse fails to ensure that the patient is properly monitored
during transport, and the patient experiences a cardiac arrest. Which of the following
actions did the nurse fail to adequately perform?
A. Make the proper nursing diagnosis.
B. Assess and analyze the level of care needed by the patient.
C. Act as a patient advocate to postpone the examination.
D. Communicate findings in a timely manner.
4. The nurse fails to record a set of vital signs on a blood transfusion report, which is against
hospital policy. The patient does not sustain any damage as a result. Can the nurse be
charged with malpractice in this case?
A. No. Documentation is not part of the duty of nurse.
B. Yes. Even though there were no damages, the nurse failed to follow hospital protocol.
C. No. There were no damages associated with failure to document
D. Yes. Failure to document always results in negligence.
,5. A bnpatient bnwith bnmetastatic bncancer bntells bnthe bnnurse, bn“I bnam bntired bnand bndo bnnot bnwant bnto
bnbe bnput bnon bna bnbreathing bnmachine.” bnThe bnpatient’s bnout-of-town bnson bnwants bn“everything
bndone bnfor bnmy
mother” bnwhen bnhis bnmother bnlater bndevelops bnrespiratory bndistress. bnWhich bnethical bnprinciples
bnare bninvolved bnin bnthis bndilemma? bn(Select bnall bnthat bnapply.)
A. Beneficence b n
B. Nonmaleficence
C. Autonomy
D. Justice
E. Paternalism
6. The bnnurse bnis bnconcerned bnthat bnthe bnphysician bnis bnignoring bnthe bnwishes bnof bnthe bnpatient
bnand bnfamily bnin bnthe bncare bnof bna bnpatient. bnThe bnnurse bnshould bntake bnthese bnconcerns bnto:
bn(Select bnall bnthat bnapply.)
A. The bnhospital bnethics bncommittee
B. The bnANA bn(American bnNurses bnAssociation)
C. The bnnursing bnsupervisor
D. The bnnursing bnethics bncommittee
E. he bnpolicy bnand bnprocedure bncommittee
7. The bnnurse bnobserves bna bncoworker bndiverting bnnarcotics bnby bnadministering bnnormal
bnsaline bnto bna bnpatient bnin bnpain. bnBy bnnot bnreporting bnthis bnobservation, bnthe bnnurse bnis bnin
bnviolation bnof bnwhat bnethical bnprinciple bnconcerning bnthe bnpatients bnunder bnthe bncare bnof bnthe
bnimpaired bnnurse?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Veracity
8. The bnfamily bnof bna bnpatient bnwho bnis bnreceiving bnmechanical bnventilation bnfor bnrespiratory
bndistress bnassociated bnwith bnan bninoperable bnbrain bntumor bnasks bnthat bnthe bnpatient bnbe
bnextubated bnto bn"allow bnnatural bndeath" bnto bnoccur. bnThis bnis bnan bnexample bnof bnwhat
bnsituation?
A. Withdrawing bntreatment
B. Rationing bncare
C. A bncriminal bnact
D. Withholding bntreatment
9. A bnnurse bnhas bnbeen bnhaving bndifficulty bnsleeping bnsince bnthe bndeath bnof bna bnpatient bnwho
bnhad bna bnstressful bnfamily bnsituation bninvolving bna bnDNR bn(do bnnot bnresuscitate) bnorder. bnShe
bnis bnarguing bnwith bnher bnhusband bnand bncoworker bnand bnis bncomplaining bnabout bnworking
bnconditions. bnThe bnnurse's bnsymptoms bncould bnbe bnsigns bnof bnwhat bnproblem?
A. Moral bndistress
B. Moral bnconfusion
C. Immoral bndistress
D. Change bnfatigue
, 10. Where bnshould bna bnnurse bnplace bnthe bnstethoscope bnwhen bnauscultating bnheart bnsounds?
Select bnall bnthat bnapply
A. First bnintercostal bnspace bnleft bnof bnthe bnsternum bnto bnhear bnsounds bnfrom bnthe bnpulmonic bnvalve bnarea.
B. Fourth bnintercostal bnspace bnto bnthe bnleft bnof bnthe bnsternum bnto bnhear bnsounds bnfrom bnthe
bntricuspid bnarea.
C. Second bnintercostal bnspace bnto bnthe bnright bnof bnthe bnsternum bnto bnhear bnsounds bnfrom bnthe
bnaortic bnvalve bnarea.
D. Fifth bnintercostal bnspace bnleft bnside bnof bnsternum bnto bnhear bnsounds bnfrom bnthe bnmitral bnarea.
E. Apex bnof bnthe bnheart bnto bnhear bnthe bnloudest bn2nd bnheart bnsound bn(S2).
11. A bnclient bnreceiving bn50 bnmL/hr bnof bnenteral bnfeedings bnhas bna bngastric bnresidual bnvolume bnof
bn200 bnmL bnand bnis bnreporting bnnausea. bnWhat bnis bnthe bnappropriate bnnursing bnintervention?
1. Stop bnthe bnfeeding bnand bnassess bngastric bnresidual bnvolume bnin bn1 bnhour.
2. Reduce bnthe bninfusion bnrate bnto bn25 bnmL/ bnhour bnand bnreevaluate bnresidual bnvolume bnin bn4
bnhours.
3. Change bnthe bnfeeding bnschedule bnfrom bncontinuous bnto bnintermittent bndelivery.
4. Discard bnthe bn200 bnmL bnand bncontinue bnthe bnfeedings bnat bnthe bnsame bnrate.
12. A bnclient bnstates, bn"I bnreally bndo bnnot bnwant bnto bngo bnthrough bnopen bnheart bnsurgery. bnI bnhave bntold
bnmy
children bnthis, bnbut bnthey bnstill bnwant bnme bnto bngo bnthrough bnwith bnthe bnsurgery. bnI bndon’t bnknow
bnwhat bnto bndo." bnWhat bnis bnthe bnbest bnresponse bnfor bnthe bnnurse bnas bnclient bnadvocate?
1. Your bnchildren bnare bncorrect. bnThe bnopen-heart bnsurgery bnis bnthe bnbest bnthing bnfor bnyour bnhealth.
2. You bnfeel bnas bnif bnyour bnchildren bnare bnnot bnaddressing bnyour bnconcerns. bnYou bnand bnyour bnfamily
bnwill bnneed bnto bnresolve bnthis bnbefore bn you bngo bnto bnsurgery.
3. I bncan bncontact bnyour bnprimary bnhealthcare bnprovider bnso bnthat bnyou bncan bndiscuss bnyour bnconcerns
bnregarding bnopen bnheart bnsurgery.
4. You bnhave bnsome bngenuine bnconcerns bnabout bnthe bnopen-heart bnsurgery, bnand bnyou bnfeel
bnas bnif bnyour bnchildren bnare bnnot bnaddressing bnyour bnconcerns.
13. The bnnurse bnis bncaring bnfor bna bnclient bnwith bna bnfibula bnfracture. bnThe bnprimary bnhealthcare
bnprovider bnmakes bnrounds bnand bnwrites bnprescriptions. bnWhat bnis bnthe bnnurse's bnbest
bnaction?
1. Check bnthe bnprescription bnprior bnto bnsending bnit bnto bnthe bnpharmacy.
2. Clarify bnthe bnprescription bnwith bnthe bnprimary bnhealthcare bnprovider.
3. Notify bnthe bnpharmacy bnthat bnthe bnprescription bnis bnneeded bnimmediately.
4. Gather bnthe bnsupplies bnneeded bnfor bnan bninjection.
14. When bnthe bnsurgical bntransport bnteam bnarrives bnto bntake bna bnclient bnto bnthe bnoperating bnroom,
bnthe bnclient bnis bnsitting bnin bna bnchair bnin bnthe bnroom. bnWhat bnis bnthe bnbest bnway bnfor bnthe
bnnurse bnto bnget bnthe bnclient bnonto bnthe bntransport bnlitter?
1. Using bna bnfoot bnstool, bnassist bnclient bnto bnstep bnup bnand bncrawl bnonto bnlitter.
2. Have bnclient bnreturn bnto bnbed bnand bnutilize bnslide bnboard bnto bntransfer bnto bnlitter.
3. With bnfeet bnplaced bnapart, bngrasp bnclient bnaround bnwaist bnand bnlift bnonto bnlitter.
4. Put bnHoyer bnpad bnunder bnclient, bnusing bnLift bnto bnmove bnclient bnfrom bnchair bnto bnlitter.
15. Which bnaction bnby bna bnnurse bnwould bnindicate bnthat bnthis bnnurse bnis bnfollowing bnstandard
bnprecautions?
