Verified Answers and Rationale
2025/2026
A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary
edema. The charge nurse would consider the medication error to constitute negligence because the
situation contains which element?
1. Purposeful failure to perform a health care procedure
C
2. Unintentional failure to perform a health care procedure
3. Act of substituting a different medication for the one ordered
4. Failure to follow a direct order by a physician
Answer: 2
LE
Rationale: Negligence is the unintentional failure of an individual to perform or not perform an act that a
reasonable person would or would not do in the same or similar circumstances. A purposeful failure to
ST
perform a procedure would be the opposite of negligence, which is unintentional. Substituting a
different medication does not fit the description of the situation in the question. Failure to follow a
direct order does not fit the description in the situation in the question.
Cognitive Level: Applying
BE
Client Need: Management of Care
Integrated Process: Nursing Process: Assessment
Content Area: Fundamentals
Strategy: Two options are opposites, which is a clue that one of them may be correct. Choose
unintentional failure to carry out a procedure over purposeful failure because it matches the definition
of negligence.
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. Non-maleficence
,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.
C
LE
A. Chloride
ST
B.Magnesium
C. Potassium
D.Phosphate
BE
B, magnesium.
Ill health, malnutrition, and wasting as a result of chronic disease are all associated with:
A. Surgical asepsis
B. Catabolism
C. Cachexia
D. Venous stasis
Correct Response: C
Ill health, malnutrition, and wasting as a result of chronic disease are all associated with cachexia.
Cachexia can also result from dehiscence of a surgical incision or rupture of wound closure.
Surgical asepsis refers to using a sterile technique to protect against infection before, during, and after
surgery. The breakdown of tissue, especially after severe trauma or crush injuries is known
as catabolism.
*Venous stasis is a disorder related to pooling of blood in a vein of the body; venous stasis typically
occurs in the lower extremities and it is one of the many hazards, or complications, of immobilization.
,Select all the possible opportunistic infections that adversely affect HIV/AIDS infected patients:
A. Visual losses
B. Kaposi's sarcoma
C. Wilms' sarcoma
D. Tuberculosis
E. Peripheral neuropathy
F. Toxoplasma gondii
Correct Response: B, D, F
Kaposi's sarcoma, tuberculosis, toxoplasma gondii, mycobacterium avium, herpes simplex,
histoplasmosis and salmonella infections are HIV/AIDS associated opportunistic infections.
*Although many affected patients can experience blindness and peripheral neuropathy, these disorders
result from impaired nervous system damage rather than an infection.
*Lastly, Wilms' tumor (sarcoma) is a pediatric form of kidney cancer and it is neither an infection nor
something that typically affects the patient with HIV/AIDS
What can help reduce a patient's anxiety and postsurgical pain?
C
A. Preoperative teaching
B. Preoperative checklist
C. Psychological counseling LE
D. Preoperative medication
Correct Response: A
Patient teaching before surgery not only helps to reduce a patient's anxiety and postsurgical pain but it
ST
also decreases the amount of anesthesia needed and a lack of anxiety additionally speeds up wound
healing. Preoperative checklists are a form of nursing documentation that is used to guide and
document the care of the patient before surgery. Psychological counseling is typically NOT necessary
except under highly unusual circumstances and preoperative medication can decrease the amount of
anesthetic needed and respiratory tract secretions but it does not help with postoperative pain.
BE
An individual has a seizure while walking down the street. During the seizure, a nurse from a
physician's office is noticed driving past without stopping to assist. The individual sues the nurse for
negligence but fails to win a judgement for which reason?
1. The nurse had no duty to the individual.
2. The nurse did what most nurses would do in the same circumstance.
3. The nurse did not cause the client's injuries.
4. The nurse was off-duty at the time.
Answer: 1
Rationale: To be guilty of negligence, the nurse must have a relationship with the client that involves a
duty to provide care. The relationship is usually a component of employment. The nurse did not
necessarily do what others would do in this situation. Although the nurse did not cause the client's
injuries, it does not prevent the nurse from assisting in this situation. Although the nurse was off-duty,
the nurse could have assisted if motivated to do so.
Cognitive Level: Understanding
Client Need: Management of Care
, Integrated Process: Nursing Process: Implementation
Content Area: Fundamentals
Strategy: Use the process of elimination and nursing knowledge. The correct answer is the one that
recognizes that the nurse was not in the role of employee at the time of the incident, removing the
requirement of acting on the client's behalf.
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
C
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
LE
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.
ST
Cognitive Level: Analyzing
Client Need: Management of Care
Integrated Process: Nursing Process: Evaluation
Content Area: Fundamentals
BE
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.
A client with cancer has decided to discontinue further treatment. Although the nurse would like the
client to continue treatment, the nurse recognizes the client is competent and supports the client's
decision using which ethical principle?
1. Justice
2. Fidelity
3. Autonomy
4. Confidentiality
Answer: 3
Rationale: Autonomy refers to the right make one's own decisions, which is the principle supported in
this situation. Justice refers to fairness. Fidelity refers to trust and loyalty. Confidentiality refers to the