Nur 115: Midterm Questions With Complete
Solutions
5 Rights of Nursing Delegation Correct Answers
Right Task
Right Circumstance
Right Person
Right Supervision
Right Direction and Communication
A client admitted to a mental health unit has
exhibited physical behaviors that put the client and
others at risk. The nurse applies four-point
restraints on the client without obtaining a
physician's order or the client's consent. The nurse
is at risk of being accused of which action? Correct
Answers Battery
A client being discharged from the hospital asks
the nurse, "When I go visit my family out of state,
should I take my living will with me, or do I need a
new one for that state?" Which is the most
appropriate response by the nurse? Correct
Answers "Take it with you. It is recognized
universally in the United States."
A client has a prescription for amoxicillin 500 mg
P.O. every 8 hours. The nurse administers the
medication via the intravenous route. Based on the
nurse's action, the client develops complications
,and has an increased length of stay. The client files
a lawsuit against the facility and the nurse. Which
legal action has the nurse's attorney identified that
meets the criteria for the client's lawsuit? Correct
Answers Malpractice
A client has had major abdominal surgery and just
returned to the unit from the operating room. The
nursing priority is to: Correct Answers complete
the postoperative assessment.
A client is newly diagnosed with diabetes and
prescribed insulin injections. The nurse identifies
the client's knowledge deficiency regarding insulin
injection. Which intervention is appropriate to
address this deficiency? Correct Answers Teach
the client how to administer insulin.
A client is unhappy with the health care provided
and informs the nurse that the client is leaving the
facility. The client has not been discharged by the
physician. The nurse finds that the client has
dressed and is ready to go. What should the
nurse's action be in this situation? Correct Answers
The nurse should call and inform the nursing
supervisor of the situation.
A client newly diagnosed with congestive heart
failure has a prescription for digoxin. The nurse
counts the heart rate before administration of the
, medication and obtains a heart rate of 51 beats per
minute. Which action by the nurse demonstrates
adherence to the standards of nursing care?
Correct Answers The nurse withholds the
medication and notifies the health care
practitioner.
Explanation: Nurses are responsible for following
the standards of care for their particular work area.
A reasonably prudent nurse would withhold the
medication and notify the health care practitioner.
All other options put the client's safety at risk and
would not be done by a reasonably prudent nurse.
A client reports hearing voices in the head that tell
the client to do bad things. When the nurse enters
the client's room, the client is talking out loud to
someone but there is nobody in the room. How
should the nurse record this assessment? Correct
Answers Document this assessment based on the
client's behaviors.
A client states that the client's recent fall was
caused by his scheduled antihypertensive
medications being mistakenly administered by two
different nurses, an event that is disputed by both
of the nurses identified by the client. Which
measure should the nurses prioritize when
anticipating that legal action may follow? Correct
Solutions
5 Rights of Nursing Delegation Correct Answers
Right Task
Right Circumstance
Right Person
Right Supervision
Right Direction and Communication
A client admitted to a mental health unit has
exhibited physical behaviors that put the client and
others at risk. The nurse applies four-point
restraints on the client without obtaining a
physician's order or the client's consent. The nurse
is at risk of being accused of which action? Correct
Answers Battery
A client being discharged from the hospital asks
the nurse, "When I go visit my family out of state,
should I take my living will with me, or do I need a
new one for that state?" Which is the most
appropriate response by the nurse? Correct
Answers "Take it with you. It is recognized
universally in the United States."
A client has a prescription for amoxicillin 500 mg
P.O. every 8 hours. The nurse administers the
medication via the intravenous route. Based on the
nurse's action, the client develops complications
,and has an increased length of stay. The client files
a lawsuit against the facility and the nurse. Which
legal action has the nurse's attorney identified that
meets the criteria for the client's lawsuit? Correct
Answers Malpractice
A client has had major abdominal surgery and just
returned to the unit from the operating room. The
nursing priority is to: Correct Answers complete
the postoperative assessment.
A client is newly diagnosed with diabetes and
prescribed insulin injections. The nurse identifies
the client's knowledge deficiency regarding insulin
injection. Which intervention is appropriate to
address this deficiency? Correct Answers Teach
the client how to administer insulin.
A client is unhappy with the health care provided
and informs the nurse that the client is leaving the
facility. The client has not been discharged by the
physician. The nurse finds that the client has
dressed and is ready to go. What should the
nurse's action be in this situation? Correct Answers
The nurse should call and inform the nursing
supervisor of the situation.
A client newly diagnosed with congestive heart
failure has a prescription for digoxin. The nurse
counts the heart rate before administration of the
, medication and obtains a heart rate of 51 beats per
minute. Which action by the nurse demonstrates
adherence to the standards of nursing care?
Correct Answers The nurse withholds the
medication and notifies the health care
practitioner.
Explanation: Nurses are responsible for following
the standards of care for their particular work area.
A reasonably prudent nurse would withhold the
medication and notify the health care practitioner.
All other options put the client's safety at risk and
would not be done by a reasonably prudent nurse.
A client reports hearing voices in the head that tell
the client to do bad things. When the nurse enters
the client's room, the client is talking out loud to
someone but there is nobody in the room. How
should the nurse record this assessment? Correct
Answers Document this assessment based on the
client's behaviors.
A client states that the client's recent fall was
caused by his scheduled antihypertensive
medications being mistakenly administered by two
different nurses, an event that is disputed by both
of the nurses identified by the client. Which
measure should the nurses prioritize when
anticipating that legal action may follow? Correct
