NR 226 UPDATED ACTUAL Questions and CORRECT
Anwers
A practitioner asks the nurse to witness an informed Correct Answer: 4 (Narcotics depress the CNS, including decision-making
consent. Which patient does the nurse identify is unable abilities.
to give an informed consent for surgery?
1 - Because legally anyone under 18 who is married can make the decision.
1) 16 year old boy who is married 2 - wrong because a depressed person can make these decisions until proven
2) 35 year old woman who is depressed mentally incompetent.
3) 50 year old woman who does not speak English 3 - Wrong because this person can provide informed consent after translations.
4) 65 year old man who has received a narcotic for
pain.
When the nurse is administering a medication to a Correct answer: 3 (This is the safest intervention because it goes to the original
confused patient, the patient says, "this pill looks source of the prescription.)
different from the one I had before." What should the
nurse do? 1 - Wrong because This action by itself is unsafe because the patient is
confused and the information obtained may be innacurate.
1) Ask what the other pill looked like. 2 - This intervention ignores the patient's concern.
2) Explain the purpose of the medication. 4 - This action ignores the patient's statement and is unsafe without obtaining
3) Check the original medication prescription. additional information.
4) Encourage the patient to take the medication.
The nurse administers an incorrect dose of a Correct answer: 3 (Risk-management committees use stats about accidents &
medication to a patient. What is the primary purpose of incidents to identify patterns of risk and prevent future accidents/incidents.)
documenting this event in an Incident Report?
1 - Wrong because although documentation of an incident may be used in a
1) Record the event for future litigation. court of law, it is not the primary reason for an incident report.
2) Provide a basis for designing new policies. 2- This is not the primary reason. New policies may or may not have to be
3) Prevent similar situations from happening again. written and implemented.
4) Ensure accountability for the cause of the accident. 4 - Although nurses are always accountable for their actions, accountability for
the cause of an incidence is the role of the courts.
A practitioner writes a prescription for a medication that Correct Answer: 4 (Nurses have a prof. resonsibility to know/investigate the
is larger than the standard dose. What should the nurse standard dose for medications being administered. In addition, nurses are
do? responsible for their own actions regardless of whether there is a written
prescription)
1) Inform the supervisor
2) Give the drug as prescribed. 1 - It is unnecessary to call the supervisor.
3) Give the average dose of the medication. 2 - This is unsafe for the patient and may result in malpractice.
4) Discuss the prescription with the practitioner. 3 - Changing a medication prescription is not within the scope of nursing
practice.
,When the nurse attempts to administer a medication to Correct Answer: 1 (The patient has the right to refuse)
a patient, the patient refuses to take the medication
because it causes diarrhea. The nurse provides teaching 2. Notifying the practitioner eventually should be done, but it is not the priority
about the medication, but the patient continues to at this time.
adamantly refuse the medication. What should the 3. Discussing the situation with a family member without the patient's consent is
nurse do first? a violation of confidentiality.
4. The patient has been taught about the medication and adamantly refuses the
1) Document the patient's refusal to take the medication. medication. Further teaching at this time may be viewed by the patient as
2) Notify the practitioner of the patient's refusal to take badgering.
the medication.
3) Discuss with a family member the need for the
patient to take the medication.
4) Explain again to the patient the consequences of
refusing to take the medication.
When caring for a terminally ill patient, a family member Correct Answer: 1 (Withholding the medication and docu- menting the patient's
says, "I need your help to hasten my mother's death so refusal are the appropriate interventions. Patient's have a right to refuse care.)
that she is no longer suffering." What should the nurse
do based on the position of the American Nurse 2. Notifying the practitioner eventually should be done, but it is not the priority
association in relation to assisted suicide? at this time.
3. Discussing the situation with a family member without the patient's consent is
1) Not participate in active euthanasia. a violation of confidentiality.
2) Participate based on personal values and beliefs. 4. The patient has been taught about the medication and adamantly refuses the
3) Participate when the patient is experiencing severe medication. Further teaching at this time may be viewed by the patient as
pain. badgering.
4) Not participate unless two practitioners are
consulted and the patient has had counseling.
Which organization is responsible for ensuring that Correct Answer: 2. (The National Council of State Boards of Nursing is
Registered Nurses are minimally qualified to practice responsible for the NCLEX examinations; however, the licensing authority in the
nursing? jurisdiction in which the graduate takes the examination verifies the acceptable
score on the examination.)
1) Sigma Theta Tau
2) State Boards of Nursing 1. Sigma Theta Tau, the international honor society of nursing, recognizes
3) American Nurses Association academic achievement and leadership qualities, encourages high professional
4) Constituent leagues of the National League for standards, fosters creative endeavors, and supports excellence in the
Nursing. profession of nursing. This organization does not grant licensure.
3. The American Nurses Association (ANA) is the national professional
organization for nursing in the United States. It fosters high standards of
nursing practice; it does not grant licensure.
4. The National League for Nursing (NLN) is committed to promoting and
improving nursing service and nursing education; it does not grant licensure
A nurse expert is called to testify in a lawsuit regarding Correct Answer: 1 (The American Nurses Association Standards of Clinical
professional nursing malpractice primarily to testify: Nursing Practice are authoritative statements by which the national
organization for nursing describes the responsibilities for which its practitioners
1. About standards of nursing care as they apply to the are accountable. An expert nurse is capable of explaining these standards as
facts in the case they apply to the situation under litigation. These professional standards are
2. With regard to laws governing the practice of nursing one criterion that helps a judge or jury determine if a nurse committed
3. For the prosecution malpractice or negligence.)
4. For the defense
2. An expert nurse is not an expert in the law. The expert nurse's role is not to
make judgments about the laws as they apply to the practice of nursing.
3. A nurse expert can testify for either the prosecution or the defense.
4. A nurse expert can testify for either the defense or the prosecution.
, The nurse initiates a visit from a member of the clergy Correct Answer: 2 (The nurse is initiating the referral to the member of the
for a patient. How is the nurse functioning when clergy and is therefore working independently. Nurses are legally permitted to
initiating this visit? diagnose and treat human responses to actual or potential health problems.)
1. Interdependently 1. The nurse does not need a practitioner's order to make a referral to a member
2. Independently of the clergy. An interdependent intervention requires a practitioner's order
3. Dependently associated with a parameter.
4. Collegially 3. This action is within the scope of nursing practice. The nurse does not need a
practitioner's order to make a referral to a member of the clergy.
4. The nurse can make a referral to a mem- ber of the clergy without
collaborating with another professional health-care team member.
A patient is asked to participate in a medical research Correct Answer: 2 (Informed consent is an agreement by a client to accept a
study. The nurse describes to the patient and family course of treatment or a procedure after receiving complete information
members how the patient is protected by the: necessary to make a knowledgeable decision.)
1. Code of Ethics 1. A code of ethics is the official statement of a group's ideals and values. It
2. Informed Consent includes broad statements that provide a basis for professional actions.
3. Nurse Practice Act 3. Nurse Practice Acts define the scope of nursing practice; they are unrelated
4. Constitution of the United States to informed consent.
4. The Constitution of the United States addresses broad individual rights and
responsibilities. The rights related to nursing practice and patients include
therights of privacy, freedom of speech, and due process.
The nurse is implementing an ordered bowel Correct Answer: 2 (Fecal material in the intestines can interfere with the
preparation for a patient who is scheduled for a visualization, collection, and analysis of data obtained through a colonoscopy,
colonoscopy. Which is the most serious consequence resulting in diagnostic errors.)
that is prevented by an effective bowel preparation?
1. Although this may occur, it is not the most serious outcome of an
1. Discomfort inappropriate preparation for a colonoscopy.
2. Misdiagnosis 3. A test may have to be cancelled or per- formed a second time if the patient
3. Wasted expense has an ineffective bowel preparation. Although this is a serious consequence, it
4. Psychological stress is not life threatening.
4. Although this is a serious consequence, it is not life threatening.
Anwers
A practitioner asks the nurse to witness an informed Correct Answer: 4 (Narcotics depress the CNS, including decision-making
consent. Which patient does the nurse identify is unable abilities.
to give an informed consent for surgery?
1 - Because legally anyone under 18 who is married can make the decision.
1) 16 year old boy who is married 2 - wrong because a depressed person can make these decisions until proven
2) 35 year old woman who is depressed mentally incompetent.
3) 50 year old woman who does not speak English 3 - Wrong because this person can provide informed consent after translations.
4) 65 year old man who has received a narcotic for
pain.
When the nurse is administering a medication to a Correct answer: 3 (This is the safest intervention because it goes to the original
confused patient, the patient says, "this pill looks source of the prescription.)
different from the one I had before." What should the
nurse do? 1 - Wrong because This action by itself is unsafe because the patient is
confused and the information obtained may be innacurate.
1) Ask what the other pill looked like. 2 - This intervention ignores the patient's concern.
2) Explain the purpose of the medication. 4 - This action ignores the patient's statement and is unsafe without obtaining
3) Check the original medication prescription. additional information.
4) Encourage the patient to take the medication.
The nurse administers an incorrect dose of a Correct answer: 3 (Risk-management committees use stats about accidents &
medication to a patient. What is the primary purpose of incidents to identify patterns of risk and prevent future accidents/incidents.)
documenting this event in an Incident Report?
1 - Wrong because although documentation of an incident may be used in a
1) Record the event for future litigation. court of law, it is not the primary reason for an incident report.
2) Provide a basis for designing new policies. 2- This is not the primary reason. New policies may or may not have to be
3) Prevent similar situations from happening again. written and implemented.
4) Ensure accountability for the cause of the accident. 4 - Although nurses are always accountable for their actions, accountability for
the cause of an incidence is the role of the courts.
A practitioner writes a prescription for a medication that Correct Answer: 4 (Nurses have a prof. resonsibility to know/investigate the
is larger than the standard dose. What should the nurse standard dose for medications being administered. In addition, nurses are
do? responsible for their own actions regardless of whether there is a written
prescription)
1) Inform the supervisor
2) Give the drug as prescribed. 1 - It is unnecessary to call the supervisor.
3) Give the average dose of the medication. 2 - This is unsafe for the patient and may result in malpractice.
4) Discuss the prescription with the practitioner. 3 - Changing a medication prescription is not within the scope of nursing
practice.
,When the nurse attempts to administer a medication to Correct Answer: 1 (The patient has the right to refuse)
a patient, the patient refuses to take the medication
because it causes diarrhea. The nurse provides teaching 2. Notifying the practitioner eventually should be done, but it is not the priority
about the medication, but the patient continues to at this time.
adamantly refuse the medication. What should the 3. Discussing the situation with a family member without the patient's consent is
nurse do first? a violation of confidentiality.
4. The patient has been taught about the medication and adamantly refuses the
1) Document the patient's refusal to take the medication. medication. Further teaching at this time may be viewed by the patient as
2) Notify the practitioner of the patient's refusal to take badgering.
the medication.
3) Discuss with a family member the need for the
patient to take the medication.
4) Explain again to the patient the consequences of
refusing to take the medication.
When caring for a terminally ill patient, a family member Correct Answer: 1 (Withholding the medication and docu- menting the patient's
says, "I need your help to hasten my mother's death so refusal are the appropriate interventions. Patient's have a right to refuse care.)
that she is no longer suffering." What should the nurse
do based on the position of the American Nurse 2. Notifying the practitioner eventually should be done, but it is not the priority
association in relation to assisted suicide? at this time.
3. Discussing the situation with a family member without the patient's consent is
1) Not participate in active euthanasia. a violation of confidentiality.
2) Participate based on personal values and beliefs. 4. The patient has been taught about the medication and adamantly refuses the
3) Participate when the patient is experiencing severe medication. Further teaching at this time may be viewed by the patient as
pain. badgering.
4) Not participate unless two practitioners are
consulted and the patient has had counseling.
Which organization is responsible for ensuring that Correct Answer: 2. (The National Council of State Boards of Nursing is
Registered Nurses are minimally qualified to practice responsible for the NCLEX examinations; however, the licensing authority in the
nursing? jurisdiction in which the graduate takes the examination verifies the acceptable
score on the examination.)
1) Sigma Theta Tau
2) State Boards of Nursing 1. Sigma Theta Tau, the international honor society of nursing, recognizes
3) American Nurses Association academic achievement and leadership qualities, encourages high professional
4) Constituent leagues of the National League for standards, fosters creative endeavors, and supports excellence in the
Nursing. profession of nursing. This organization does not grant licensure.
3. The American Nurses Association (ANA) is the national professional
organization for nursing in the United States. It fosters high standards of
nursing practice; it does not grant licensure.
4. The National League for Nursing (NLN) is committed to promoting and
improving nursing service and nursing education; it does not grant licensure
A nurse expert is called to testify in a lawsuit regarding Correct Answer: 1 (The American Nurses Association Standards of Clinical
professional nursing malpractice primarily to testify: Nursing Practice are authoritative statements by which the national
organization for nursing describes the responsibilities for which its practitioners
1. About standards of nursing care as they apply to the are accountable. An expert nurse is capable of explaining these standards as
facts in the case they apply to the situation under litigation. These professional standards are
2. With regard to laws governing the practice of nursing one criterion that helps a judge or jury determine if a nurse committed
3. For the prosecution malpractice or negligence.)
4. For the defense
2. An expert nurse is not an expert in the law. The expert nurse's role is not to
make judgments about the laws as they apply to the practice of nursing.
3. A nurse expert can testify for either the prosecution or the defense.
4. A nurse expert can testify for either the defense or the prosecution.
, The nurse initiates a visit from a member of the clergy Correct Answer: 2 (The nurse is initiating the referral to the member of the
for a patient. How is the nurse functioning when clergy and is therefore working independently. Nurses are legally permitted to
initiating this visit? diagnose and treat human responses to actual or potential health problems.)
1. Interdependently 1. The nurse does not need a practitioner's order to make a referral to a member
2. Independently of the clergy. An interdependent intervention requires a practitioner's order
3. Dependently associated with a parameter.
4. Collegially 3. This action is within the scope of nursing practice. The nurse does not need a
practitioner's order to make a referral to a member of the clergy.
4. The nurse can make a referral to a mem- ber of the clergy without
collaborating with another professional health-care team member.
A patient is asked to participate in a medical research Correct Answer: 2 (Informed consent is an agreement by a client to accept a
study. The nurse describes to the patient and family course of treatment or a procedure after receiving complete information
members how the patient is protected by the: necessary to make a knowledgeable decision.)
1. Code of Ethics 1. A code of ethics is the official statement of a group's ideals and values. It
2. Informed Consent includes broad statements that provide a basis for professional actions.
3. Nurse Practice Act 3. Nurse Practice Acts define the scope of nursing practice; they are unrelated
4. Constitution of the United States to informed consent.
4. The Constitution of the United States addresses broad individual rights and
responsibilities. The rights related to nursing practice and patients include
therights of privacy, freedom of speech, and due process.
The nurse is implementing an ordered bowel Correct Answer: 2 (Fecal material in the intestines can interfere with the
preparation for a patient who is scheduled for a visualization, collection, and analysis of data obtained through a colonoscopy,
colonoscopy. Which is the most serious consequence resulting in diagnostic errors.)
that is prevented by an effective bowel preparation?
1. Although this may occur, it is not the most serious outcome of an
1. Discomfort inappropriate preparation for a colonoscopy.
2. Misdiagnosis 3. A test may have to be cancelled or per- formed a second time if the patient
3. Wasted expense has an ineffective bowel preparation. Although this is a serious consequence, it
4. Psychological stress is not life threatening.
4. Although this is a serious consequence, it is not life threatening.
