NCLEX Questions-Ethical and Legal
Issues
1. The nurse hears a client calling out for help, hurries down the hallway to the client's
room, and finds the client lying on the floor. The nurse performs an assessment, assists
the client back to bed, notifies the health care provider of the incident, and completes an
incident report. Which statement should the nurse document on the incident report?
a. The client fell out of bed
b. The client climbed over the side rails
c. The client was found lying on the floor
d. The client became restless and tried to get out of bed. - 1. C- The incident report
should contain the client's name, age, and diagnosis. The report should contain a
factual description of the incident, any injuries experienced by those involved, and the
outcome of the situation. The correct option is the only one that describes the facts as
observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are
not factual information as observed by the nurse.
2. A client is brought to the emergency department by emergency medical services
(EMS) after being hit by a car. The name of the client is unknown, and the client has
sustained a severe head injury and multiple fractures and is unconscious. An
emergency craniotomy is required. Regarding informed consent for the surgical
procedure, which is the best action?
a. Obtain a court order for the surgical procedure
b. Ask the EMS team to sign the informed consent
c. Transport the victim to the operating room for surgery
d. Call the police to identify the client and locate the family. - 2. C- In general, there are
two situations in which informed consent of an adult client is not needed. One is when
an emergency is present and delaying treatment for the purpose of obtaining informed
consent would result in injury or death to the client. The second is when the client
waives the right to give informed consent. Option 1 will delay emergency treatment, and
option 2 is inappropriate. Although option 4 may be pursued, it is not the best action
3. The nurse has just assisted a client back to bed after a fall. The nurse and health
care provider have assessed the client and have determined that the client is not
injured. After completing the incident report, the nurse should implement which action
net?
a. Reassess the client
b. Conduct a staff meeting to describe the fall
c. Document in the nurse's notes that an incident report was completed.
d. Contact the nursing supervisor to update information regarding the fall - 3. A- After a
client's fall, the nurse must frequently reassess the client because potential
complications do not always appear immediately after the fall. The client's fall should be
treated as private information and shared on a "need to know" basis. Communication
, regarding the event should involve only the individuals participating in the client's care.
An incident report is a problem-solving document; however, its completion is not
documented in the nurse's notes. If the nursing supervisor has been made aware of the
incident, the supervisor will contact the nurse if status update is necessary.
4. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU)
for the day because the ICU is understaffed and needs additional nurses to care for the
clients. The nurse has never worked in the ICU. The nurse should take which action
first?
a. Call the hospital lawyer
b. Refuse to float to the ICU
c. Call the nursing supervisor
d. Identify tasks that can be performed safely in the ICU - 4. D- Floating is an
acceptable legal practice used by hospitals to solve understaffing problems. Legally, the
nurse cannot refuse to float unless a union contract guarantees that nurses can work
only in a specified area or the nurse can prove the lack of knowledge for the
performance of assigned tasks. When encountering this situation, the nurse should set
priorities and identify potential areas of harm to the client. The nursing supervisor is
called if the nurse is expected to perform tasks that he or she cannot safely perform.
Calling the hospital lawyer is a premature action.
5. The nurse who works on the night shift enters the medication room and finds a co-
worker with a tourniquet wrapped around the upper arm. The co-worker is about to
insert a needle, attached to a syringe containing clear liquid, in the antecubital area.
Which is the most appropriate action by the nurse?
a. Call security
b. Call the police
c. Call the nursing supervisor
d. Lock the co-worker in the medication room until help is obtain - 5. C- Nurse practice
acts require reporting impaired nurses. The board of nursing has jurisdiction over the
practice of nursing and may develop plans for treatment and supervision of the impaired
nurse. This incident needs to be reported to the nursing supervisor, who will then report
to the board of nursing and other authorities, such as the police, as required. The nurse
may call security if a disturbance occurs, but no information in the question supports this
need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe
action.
6. A hospitalized client tells the nurse that a living will is being prepared and that the
lawyer will be bringing the will to the hospital today for witness signatures. The client
asks the nurse for assistance obtaining a witness to the will. Which is the most
appropriate response to the client?
a. "I will sign as a witness to your signature."
b. "You will need to find a witness on your own.'
c. "Whoever is available at the time will sign as a witness for you."
d. "I will call the nursing supervisor to seek assistance regarding your request." - 6. D-
Living wills, also known as natural death acts in some states, are required to be in
Issues
1. The nurse hears a client calling out for help, hurries down the hallway to the client's
room, and finds the client lying on the floor. The nurse performs an assessment, assists
the client back to bed, notifies the health care provider of the incident, and completes an
incident report. Which statement should the nurse document on the incident report?
a. The client fell out of bed
b. The client climbed over the side rails
c. The client was found lying on the floor
d. The client became restless and tried to get out of bed. - 1. C- The incident report
should contain the client's name, age, and diagnosis. The report should contain a
factual description of the incident, any injuries experienced by those involved, and the
outcome of the situation. The correct option is the only one that describes the facts as
observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are
not factual information as observed by the nurse.
2. A client is brought to the emergency department by emergency medical services
(EMS) after being hit by a car. The name of the client is unknown, and the client has
sustained a severe head injury and multiple fractures and is unconscious. An
emergency craniotomy is required. Regarding informed consent for the surgical
procedure, which is the best action?
a. Obtain a court order for the surgical procedure
b. Ask the EMS team to sign the informed consent
c. Transport the victim to the operating room for surgery
d. Call the police to identify the client and locate the family. - 2. C- In general, there are
two situations in which informed consent of an adult client is not needed. One is when
an emergency is present and delaying treatment for the purpose of obtaining informed
consent would result in injury or death to the client. The second is when the client
waives the right to give informed consent. Option 1 will delay emergency treatment, and
option 2 is inappropriate. Although option 4 may be pursued, it is not the best action
3. The nurse has just assisted a client back to bed after a fall. The nurse and health
care provider have assessed the client and have determined that the client is not
injured. After completing the incident report, the nurse should implement which action
net?
a. Reassess the client
b. Conduct a staff meeting to describe the fall
c. Document in the nurse's notes that an incident report was completed.
d. Contact the nursing supervisor to update information regarding the fall - 3. A- After a
client's fall, the nurse must frequently reassess the client because potential
complications do not always appear immediately after the fall. The client's fall should be
treated as private information and shared on a "need to know" basis. Communication
, regarding the event should involve only the individuals participating in the client's care.
An incident report is a problem-solving document; however, its completion is not
documented in the nurse's notes. If the nursing supervisor has been made aware of the
incident, the supervisor will contact the nurse if status update is necessary.
4. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU)
for the day because the ICU is understaffed and needs additional nurses to care for the
clients. The nurse has never worked in the ICU. The nurse should take which action
first?
a. Call the hospital lawyer
b. Refuse to float to the ICU
c. Call the nursing supervisor
d. Identify tasks that can be performed safely in the ICU - 4. D- Floating is an
acceptable legal practice used by hospitals to solve understaffing problems. Legally, the
nurse cannot refuse to float unless a union contract guarantees that nurses can work
only in a specified area or the nurse can prove the lack of knowledge for the
performance of assigned tasks. When encountering this situation, the nurse should set
priorities and identify potential areas of harm to the client. The nursing supervisor is
called if the nurse is expected to perform tasks that he or she cannot safely perform.
Calling the hospital lawyer is a premature action.
5. The nurse who works on the night shift enters the medication room and finds a co-
worker with a tourniquet wrapped around the upper arm. The co-worker is about to
insert a needle, attached to a syringe containing clear liquid, in the antecubital area.
Which is the most appropriate action by the nurse?
a. Call security
b. Call the police
c. Call the nursing supervisor
d. Lock the co-worker in the medication room until help is obtain - 5. C- Nurse practice
acts require reporting impaired nurses. The board of nursing has jurisdiction over the
practice of nursing and may develop plans for treatment and supervision of the impaired
nurse. This incident needs to be reported to the nursing supervisor, who will then report
to the board of nursing and other authorities, such as the police, as required. The nurse
may call security if a disturbance occurs, but no information in the question supports this
need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe
action.
6. A hospitalized client tells the nurse that a living will is being prepared and that the
lawyer will be bringing the will to the hospital today for witness signatures. The client
asks the nurse for assistance obtaining a witness to the will. Which is the most
appropriate response to the client?
a. "I will sign as a witness to your signature."
b. "You will need to find a witness on your own.'
c. "Whoever is available at the time will sign as a witness for you."
d. "I will call the nursing supervisor to seek assistance regarding your request." - 6. D-
Living wills, also known as natural death acts in some states, are required to be in
