1) The nurse is providing discharge instructions to a Chinese Americanclient regarding prescribed
dietary modifications. During the teachingsession, the client continuously turns away from the nurse.
The nurse should implement which best action?
Answers-Continue with the instructions, verifying clientunderstanding.
1) A critically ill Hispanic client tells the nurse through aninterpreter that she is Roman
Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on
the client's statements, which actions by the nurse demonstrate cultural sensitivity and
spiritual
support? Select all that apply.(1,2,5)
Answers-Ensures that a closerelative stays with the client
Makes a referral for a Catholicpriest to visit the client
Offers to provide a means for praying the rosary if the client wishes.
2) Which clients have a high risk of obesity and diabetesmellitus? Select all that
apply.(1,2,4,5)
Latino American Man
Native American man
Hispanic American man
African American woman
3) The nurse is preparing a plan of care for a client, and isasking the client about religious
preferences. The nurse considers the client's religious preferences as being
characteristic of a Jehovah's Witness if which client statement is made?
I cannot have any food containing or prepared with blood."
4) The ambulatory care nurse is discussing preoperative procedures with a Japanese
American client who is scheduledfor surgery the following week. During the discussion,
the client continually smiles and nods the head. How should thenurse interpret this
nonverbal behavior?
, Answers-Reflecting a cultural value
5) When communicating with a client who speaks a different language, which best
practice should the nurse implement?
Arrange for an interpreter totranslate.
6) The nurse educator is providing in-service education to thenursing staff regarding
transcultural nursing care; a staffmember asks the nurse educator to provide an example
of theconcept of acculturation. The nurse educator should make which most appropriate
response?
Answers-"A person who moves from China to the United States (U.S.) and learns about and
adapts to the culture in the U.S."
7) An Asin American client is experiencing a fever. The nurseplans care so that the client
can self-treat the disorder using which method?
Foods considered to be yin
8) Which meal tray should the nurse deliver to a client ofOrthodox Judaism faith who
follows a kosher diet?
Sweet and sour chicken with rice and vegetables, mixed fruit, juice.
9) Which is the best nursing intervention regardingcomplementary and
alternative medicine?
Educating the client about therapies that he or she is using or is interested in using
10) An antihypertensive medication has been prescribed fora client with hypertension.
The client tells the clinic nurse that he would like to take an herbal substance to helplower
his blood pressure. The nurse should take which action?
,Encourage the client to discuss theuse of an herbal substance with the health care provider
(HCP).
11) The nurse educator asks a student to list the 5 maincategories of
complementary and alternative medicine (CAM),developed by the National Center for
Complementary and Alternative Medicine. Which statement, if made by the nursing
student, indicates a need for further
teaching regarding CAM categories?
"Magnetic therapy and massage therapy are a focus of CAM."
12) The nurse hears a client calling out for help, hurriesdown the hallway to the
client's room, and finds the clientlying 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?
The client was found lying on the floor.
13) 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 isunconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure, which is
the best action?
Transport the victim to the operating room for surgery.
14) The nurse has just assisted a client back to bed aftera fall. The nurse and health
care provider have assessed theclient and have determined that the client is not injured.
After completing the incident report, the nurse should implement which action next?
, Reassess the client.
15) The nurse arrives at work and is told to report (float)to the intensive care unit
(ICU) for the day because the ICUis understaffed and needs additional nurses to care for
the clients. The nurse has never worked in the ICU. The nurse should take which best
action?
Clarify with the team leader to make a safe ICU client assignment.
16) 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 a clearliquid, into the
antecubital area. Which is the most appropriate action by the nurse?
Call the nursing supervisor.
17) A hospitalized client tells the nurse that an instructional directive is being
prepared and that the lawyer will be bringing the document to the hospital todayfor
witness signatures. The client asks the nurse for assistance in obtaining a witness to
the will. Which is the most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your request."
19) The nurse has made an error in a narrative documentationof an assessment finding
on a client and obtains the client's record to correct the error. The nurse should take
which actions to correct the error? Select all that apply.
Document the correct information and end with the nurse's signature and title.
Draw 1 line through the error,initialing and dating it.
dietary modifications. During the teachingsession, the client continuously turns away from the nurse.
The nurse should implement which best action?
Answers-Continue with the instructions, verifying clientunderstanding.
1) A critically ill Hispanic client tells the nurse through aninterpreter that she is Roman
Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on
the client's statements, which actions by the nurse demonstrate cultural sensitivity and
spiritual
support? Select all that apply.(1,2,5)
Answers-Ensures that a closerelative stays with the client
Makes a referral for a Catholicpriest to visit the client
Offers to provide a means for praying the rosary if the client wishes.
2) Which clients have a high risk of obesity and diabetesmellitus? Select all that
apply.(1,2,4,5)
Latino American Man
Native American man
Hispanic American man
African American woman
3) The nurse is preparing a plan of care for a client, and isasking the client about religious
preferences. The nurse considers the client's religious preferences as being
characteristic of a Jehovah's Witness if which client statement is made?
I cannot have any food containing or prepared with blood."
4) The ambulatory care nurse is discussing preoperative procedures with a Japanese
American client who is scheduledfor surgery the following week. During the discussion,
the client continually smiles and nods the head. How should thenurse interpret this
nonverbal behavior?
, Answers-Reflecting a cultural value
5) When communicating with a client who speaks a different language, which best
practice should the nurse implement?
Arrange for an interpreter totranslate.
6) The nurse educator is providing in-service education to thenursing staff regarding
transcultural nursing care; a staffmember asks the nurse educator to provide an example
of theconcept of acculturation. The nurse educator should make which most appropriate
response?
Answers-"A person who moves from China to the United States (U.S.) and learns about and
adapts to the culture in the U.S."
7) An Asin American client is experiencing a fever. The nurseplans care so that the client
can self-treat the disorder using which method?
Foods considered to be yin
8) Which meal tray should the nurse deliver to a client ofOrthodox Judaism faith who
follows a kosher diet?
Sweet and sour chicken with rice and vegetables, mixed fruit, juice.
9) Which is the best nursing intervention regardingcomplementary and
alternative medicine?
Educating the client about therapies that he or she is using or is interested in using
10) An antihypertensive medication has been prescribed fora client with hypertension.
The client tells the clinic nurse that he would like to take an herbal substance to helplower
his blood pressure. The nurse should take which action?
,Encourage the client to discuss theuse of an herbal substance with the health care provider
(HCP).
11) The nurse educator asks a student to list the 5 maincategories of
complementary and alternative medicine (CAM),developed by the National Center for
Complementary and Alternative Medicine. Which statement, if made by the nursing
student, indicates a need for further
teaching regarding CAM categories?
"Magnetic therapy and massage therapy are a focus of CAM."
12) The nurse hears a client calling out for help, hurriesdown the hallway to the
client's room, and finds the clientlying 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?
The client was found lying on the floor.
13) 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 isunconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure, which is
the best action?
Transport the victim to the operating room for surgery.
14) The nurse has just assisted a client back to bed aftera fall. The nurse and health
care provider have assessed theclient and have determined that the client is not injured.
After completing the incident report, the nurse should implement which action next?
, Reassess the client.
15) The nurse arrives at work and is told to report (float)to the intensive care unit
(ICU) for the day because the ICUis understaffed and needs additional nurses to care for
the clients. The nurse has never worked in the ICU. The nurse should take which best
action?
Clarify with the team leader to make a safe ICU client assignment.
16) 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 a clearliquid, into the
antecubital area. Which is the most appropriate action by the nurse?
Call the nursing supervisor.
17) A hospitalized client tells the nurse that an instructional directive is being
prepared and that the lawyer will be bringing the document to the hospital todayfor
witness signatures. The client asks the nurse for assistance in obtaining a witness to
the will. Which is the most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your request."
19) The nurse has made an error in a narrative documentationof an assessment finding
on a client and obtains the client's record to correct the error. The nurse should take
which actions to correct the error? Select all that apply.
Document the correct information and end with the nurse's signature and title.
Draw 1 line through the error,initialing and dating it.
