NURS 103: Documentation & Legal/Ethical Responsibilities
(2026/2027 Update) WCU
1. A nurse discovers that a colleague has shared a patient’s sensitive diagnostic
information on a private social media group. Which regulatory body or act is
primarily violated in this scenario?
A. The Patient Self-Determination Act (PSDA)
B. The Joint Commission (TJC) safety standards
C. Health Insurance Portability and Accountability Act (HIPAA)
D. The Emergency Medical Treatment and Labor Act (EMTALA)
Answer: C
Rationale: HIPAA establishes national standards for the protection of highly sensitive
patient health information from being disclosed without the patient’s consent or
knowledge.
2. Which of the following actions by a nurse constitutes ‘battery’?
A. Administering an injection despite the patient’s verbal and physical refusal
B. Performing a surgical procedure without a signed consent form
C. Threatening to insert a nasogastric tube if a patient refuses to eat
D. Telling a patient they cannot leave the hospital until their bill is paid
Answer: A
Rationale: Battery is the intentional and wrongful physical contact with a person without
their consent that entails some injury or offensive touching.
,3. A nurse is documenting in a patient’s electronic health record (EHR). Which
entry is considered most objective and professional?
A. Patient shouted ‘Go away’ and pushed the nurse’s hand away during the dressing change.
B. Patient appears to be in a great deal of pain today.
C. Patient’s wound is healing poorly; patient seems depressed.
D. Patient was belligerent and uncooperative during the dressing change.
Answer: A
Rationale: Objective documentation focuses on factual, observable, and measurable data
rather than interpretations or labels like ‘belligerent’ or ‘depressed’.
4. A nurse is faced with an ethical dilemma regarding a patient’s end-of-life
care. The nurse decides to follow the principle of ‘Beneficence’. What does this
principle entail?
A. The duty to do no harm to the patient.
B. The obligation to act in the best interest of the patient to promote good.
C. Respecting the patient’s right to self-determination.
D. Ensuring that resources are distributed fairly among all patients.
Answer: B
Rationale: Beneficence is the ethical principle of doing good and taking positive actions to
help others.
5. A nurse realizes that they administered the wrong dose of medication. What
is the priority nursing action?
A. Assess the patient’s condition and vital signs.
B. Notify the provider and the nurse manager.
C. Immediately complete an incident/occurrence report.
D. Document the error in the patient’s progress notes to ensure transparency.
Answer: A
, Rationale: The first priority after a medication error is always the safety and assessment of
the patient to monitor for adverse effects.
6. When witnessing a patient sign an informed consent form for surgery, what is
the nurse primarily attesting to?
A. That the patient fully understands the risks and benefits of the procedure.
B. That the surgeon has explained all alternative treatments.
C. That the nurse has answered all the patient’s clinical questions about the surgery.
D. That the signature is authentic and the patient appears competent to give consent.
Answer: D
Rationale: The nurse’s signature as a witness confirms that the patient voluntarily signed
the form, is who they say they are, and appears capable of providing consent.
7. A patient has a ‘Do Not Resuscitate’ (DNR) order. During a shift, the patient
stops breathing. What is the nurse’s legal obligation?
A. Initiate CPR immediately if the family requests it.
B. Call a ‘Code Blue’ but do not perform chest compressions.
C. Follow the order and withhold life-saving measures.
D. Contact the ethics committee before taking any action.
Answer: C
Rationale: A valid DNR order is a legal document that instructs healthcare providers to
withhold CPR and other life-saving measures in the event of cardiac or respiratory arrest.
8. A nurse is using the SBAR communication tool. Which part of SBAR involves
the nurse suggesting a specific intervention or plan of action?
A. S (Situation)
B. B (Background)
C. A (Assessment)
D. R (Recommendation)
Answer: D
(2026/2027 Update) WCU
1. A nurse discovers that a colleague has shared a patient’s sensitive diagnostic
information on a private social media group. Which regulatory body or act is
primarily violated in this scenario?
A. The Patient Self-Determination Act (PSDA)
B. The Joint Commission (TJC) safety standards
C. Health Insurance Portability and Accountability Act (HIPAA)
D. The Emergency Medical Treatment and Labor Act (EMTALA)
Answer: C
Rationale: HIPAA establishes national standards for the protection of highly sensitive
patient health information from being disclosed without the patient’s consent or
knowledge.
2. Which of the following actions by a nurse constitutes ‘battery’?
A. Administering an injection despite the patient’s verbal and physical refusal
B. Performing a surgical procedure without a signed consent form
C. Threatening to insert a nasogastric tube if a patient refuses to eat
D. Telling a patient they cannot leave the hospital until their bill is paid
Answer: A
Rationale: Battery is the intentional and wrongful physical contact with a person without
their consent that entails some injury or offensive touching.
,3. A nurse is documenting in a patient’s electronic health record (EHR). Which
entry is considered most objective and professional?
A. Patient shouted ‘Go away’ and pushed the nurse’s hand away during the dressing change.
B. Patient appears to be in a great deal of pain today.
C. Patient’s wound is healing poorly; patient seems depressed.
D. Patient was belligerent and uncooperative during the dressing change.
Answer: A
Rationale: Objective documentation focuses on factual, observable, and measurable data
rather than interpretations or labels like ‘belligerent’ or ‘depressed’.
4. A nurse is faced with an ethical dilemma regarding a patient’s end-of-life
care. The nurse decides to follow the principle of ‘Beneficence’. What does this
principle entail?
A. The duty to do no harm to the patient.
B. The obligation to act in the best interest of the patient to promote good.
C. Respecting the patient’s right to self-determination.
D. Ensuring that resources are distributed fairly among all patients.
Answer: B
Rationale: Beneficence is the ethical principle of doing good and taking positive actions to
help others.
5. A nurse realizes that they administered the wrong dose of medication. What
is the priority nursing action?
A. Assess the patient’s condition and vital signs.
B. Notify the provider and the nurse manager.
C. Immediately complete an incident/occurrence report.
D. Document the error in the patient’s progress notes to ensure transparency.
Answer: A
, Rationale: The first priority after a medication error is always the safety and assessment of
the patient to monitor for adverse effects.
6. When witnessing a patient sign an informed consent form for surgery, what is
the nurse primarily attesting to?
A. That the patient fully understands the risks and benefits of the procedure.
B. That the surgeon has explained all alternative treatments.
C. That the nurse has answered all the patient’s clinical questions about the surgery.
D. That the signature is authentic and the patient appears competent to give consent.
Answer: D
Rationale: The nurse’s signature as a witness confirms that the patient voluntarily signed
the form, is who they say they are, and appears capable of providing consent.
7. A patient has a ‘Do Not Resuscitate’ (DNR) order. During a shift, the patient
stops breathing. What is the nurse’s legal obligation?
A. Initiate CPR immediately if the family requests it.
B. Call a ‘Code Blue’ but do not perform chest compressions.
C. Follow the order and withhold life-saving measures.
D. Contact the ethics committee before taking any action.
Answer: C
Rationale: A valid DNR order is a legal document that instructs healthcare providers to
withhold CPR and other life-saving measures in the event of cardiac or respiratory arrest.
8. A nurse is using the SBAR communication tool. Which part of SBAR involves
the nurse suggesting a specific intervention or plan of action?
A. S (Situation)
B. B (Background)
C. A (Assessment)
D. R (Recommendation)
Answer: D
