NUR 101 | NUR 101 Nursing Fundamentals Exam 4
Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient decides to refuse a life-saving blood transfusion due to religious beliefs.
What is the nurse’s primary responsibility in this situation?
A. To persuade the patient to accept the treatment for their own safety.
B. To support the patient’s right to refuse and document the decision.
C. To notify the hospital chaplain to convince the patient otherwise.
D. To administer the transfusion anyway under implied consent.
Correct Answer: B
Expert Explanation: Patient advocacy requires the nurse to support the client’s
autonomy and right to refuse treatment. The nurse must ensure the client is fully
informed of the potential risks associated with refusing the care. Documentation of
the refusal and the education provided is a critical legal requirement for the nurse.
Notifying the provider is necessary to discuss alternative treatment plans that align
with the patient’s beliefs. Respecting the patient’s values is a fundamental aspect of
ethical nursing practice.
2. Which element is necessary to prove professional negligence or malpractice in a
court of law?
A. The nurse intended to cause harm to the patient.
,B. The nurse failed to follow the provider’s orders exactly as written.
C. A breach of duty directly caused identifiable injury or damage.
D. The patient was dissatisfied with the quality of care received.
Correct Answer: C
Expert Explanation: Negligence requires the presence of duty, breach of duty,
causation, and actual harm or damages. The nurse must have had a professional
obligation to provide care according to established standards. A breach occurs when
the nurse fails to meet the standard of care expected in that situation. Causation
links the nurse’s failure directly to the injury sustained by the patient. Without
demonstrable harm or injury, a claim of negligence cannot be legally sustained.
3. When witnessing a patient sign an informed consent form, what is the nurse’s legal
role?
A. To explain the surgical risks and benefits to the patient.
B. To verify that the signature is authentic and given voluntarily.
C. To ensure the patient has no remaining questions about the surgery.
D. To provide a second opinion regarding the necessity of the procedure.
Correct Answer: B
,Expert Explanation: The nurse acts as a witness to the signature, confirming that
the patient is competent and signing without coercion. It remains the physician’s
legal responsibility to explain the procedure and its associated risks. If the nurse
discovers the patient does not understand the procedure, the surgeon must be
called back to explain. The nurse confirms the patient is not under the influence of
medications that impair judgment. Proper documentation of the witnessed
signature protects both the patient and the healthcare facility.
4. A nurse shares a patient’s lab results with a family member who is not on the
authorized disclosure list. This is a violation of:
A. The Patient Self-Determination Act.
B. The Emergency Medical Treatment and Labor Act (EMTALA).
C. The Good Samaritan Law.
D. The Health Insurance Portability and Accountability Act (HIPAA).
Correct Answer: D
Expert Explanation: HIPAA mandates the protection of sensitive patient health
information from unauthorized disclosure. Nurses must only share information with
individuals whom the patient has explicitly authorized. Even well-meaning family
members cannot receive updates without the patient’s legal consent. This principle
of confidentiality is essential for maintaining trust within the nurse-patient
, relationship. Violating HIPAA can lead to significant legal penalties and disciplinary
action by the board of nursing.
5. Which of the following patients should the nurse prioritize for assessment after
receiving the morning shift report?
A. A patient with a fractured hip who is requesting pain medication.
B. A patient with new-onset shortness of breath and clear lung sounds.
C. A patient who had a colonoscopy yesterday and is ready for discharge.
D. A patient with chronic COPD and an oxygen saturation of 91%.
Correct Answer: B
Expert Explanation: The nurse must use the ABC (Airway, Breathing, Circulation)
framework to prioritize patient care. New-onset shortness of breath indicates a
potentially life-threatening respiratory or cardiac issue that requires immediate
assessment. While pain management is important, physiological stability always
takes precedence over comfort. Chronic conditions like COPD often have lower
baseline oxygen levels that are not as urgent as acute changes. Rapid intervention in
acute cases can prevent further deterioration and improve patient outcomes.
6. A nurse delegates the task of taking vital signs to an unlicensed assistive personnel
(UAP). Who holds ultimate accountability for the accuracy of these vitals?
A. The UAP who performed the task.
Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient decides to refuse a life-saving blood transfusion due to religious beliefs.
What is the nurse’s primary responsibility in this situation?
A. To persuade the patient to accept the treatment for their own safety.
B. To support the patient’s right to refuse and document the decision.
C. To notify the hospital chaplain to convince the patient otherwise.
D. To administer the transfusion anyway under implied consent.
Correct Answer: B
Expert Explanation: Patient advocacy requires the nurse to support the client’s
autonomy and right to refuse treatment. The nurse must ensure the client is fully
informed of the potential risks associated with refusing the care. Documentation of
the refusal and the education provided is a critical legal requirement for the nurse.
Notifying the provider is necessary to discuss alternative treatment plans that align
with the patient’s beliefs. Respecting the patient’s values is a fundamental aspect of
ethical nursing practice.
2. Which element is necessary to prove professional negligence or malpractice in a
court of law?
A. The nurse intended to cause harm to the patient.
,B. The nurse failed to follow the provider’s orders exactly as written.
C. A breach of duty directly caused identifiable injury or damage.
D. The patient was dissatisfied with the quality of care received.
Correct Answer: C
Expert Explanation: Negligence requires the presence of duty, breach of duty,
causation, and actual harm or damages. The nurse must have had a professional
obligation to provide care according to established standards. A breach occurs when
the nurse fails to meet the standard of care expected in that situation. Causation
links the nurse’s failure directly to the injury sustained by the patient. Without
demonstrable harm or injury, a claim of negligence cannot be legally sustained.
3. When witnessing a patient sign an informed consent form, what is the nurse’s legal
role?
A. To explain the surgical risks and benefits to the patient.
B. To verify that the signature is authentic and given voluntarily.
C. To ensure the patient has no remaining questions about the surgery.
D. To provide a second opinion regarding the necessity of the procedure.
Correct Answer: B
,Expert Explanation: The nurse acts as a witness to the signature, confirming that
the patient is competent and signing without coercion. It remains the physician’s
legal responsibility to explain the procedure and its associated risks. If the nurse
discovers the patient does not understand the procedure, the surgeon must be
called back to explain. The nurse confirms the patient is not under the influence of
medications that impair judgment. Proper documentation of the witnessed
signature protects both the patient and the healthcare facility.
4. A nurse shares a patient’s lab results with a family member who is not on the
authorized disclosure list. This is a violation of:
A. The Patient Self-Determination Act.
B. The Emergency Medical Treatment and Labor Act (EMTALA).
C. The Good Samaritan Law.
D. The Health Insurance Portability and Accountability Act (HIPAA).
Correct Answer: D
Expert Explanation: HIPAA mandates the protection of sensitive patient health
information from unauthorized disclosure. Nurses must only share information with
individuals whom the patient has explicitly authorized. Even well-meaning family
members cannot receive updates without the patient’s legal consent. This principle
of confidentiality is essential for maintaining trust within the nurse-patient
, relationship. Violating HIPAA can lead to significant legal penalties and disciplinary
action by the board of nursing.
5. Which of the following patients should the nurse prioritize for assessment after
receiving the morning shift report?
A. A patient with a fractured hip who is requesting pain medication.
B. A patient with new-onset shortness of breath and clear lung sounds.
C. A patient who had a colonoscopy yesterday and is ready for discharge.
D. A patient with chronic COPD and an oxygen saturation of 91%.
Correct Answer: B
Expert Explanation: The nurse must use the ABC (Airway, Breathing, Circulation)
framework to prioritize patient care. New-onset shortness of breath indicates a
potentially life-threatening respiratory or cardiac issue that requires immediate
assessment. While pain management is important, physiological stability always
takes precedence over comfort. Chronic conditions like COPD often have lower
baseline oxygen levels that are not as urgent as acute changes. Rapid intervention in
acute cases can prevent further deterioration and improve patient outcomes.
6. A nurse delegates the task of taking vital signs to an unlicensed assistive personnel
(UAP). Who holds ultimate accountability for the accuracy of these vitals?
A. The UAP who performed the task.
