,
,
,
, Evaluation consists of determining whether the desired patient outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
9. Which of the following would the nurse perform during the assessment phase of the nursing
process?
a. Obtains data with which to diagnose patient problems.
b. Uses patient data to develop priority nursing diagnoses.
c. Teaches interventions to relieve patient health problems.
d. Assists the patient to identify realistic outcomes to health problems.
ANS: A
During the assessment phase, the nurse gathers information about the patient. The other
responses are examples of the intervention, diagnosis, and planning phases of the nursing
process.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
10. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to insufficient sense of control
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
a patient’s response to a health problem that can be treated by nursing. The use of a medical
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
uses the defining characteristics as the etiology.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
11. Which of the following includes the components required for a complete nursing diagnosis
statement?
a. A problem and the suggested patient goals or outcomes
b. A problem, its cause, and objective data that support the problem
c. A problem with all its possible causes and the planned interventions
d. A problem with its etiology and the signs and symptoms of the problem
ANS: D
The PES format is used when writing nursing diagnoses. The subjective, as well as objective,
data should be included in the defining characteristics. Interventions and outcomes are not
included in the nursing diagnosis statement.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
,12. Which of the following refers to a situation that results in unintended harm to the patient and
is related to the care or services provided rather than the patient’s medical condition?
a. Negligence
b. Adverse event
c. Incident report
d. Nonmaleficence
ANS: B
An adverse event is an event that results in unintended harm to the patient and is related to the
care or services provided to the patient rather than to the patient’s underlying medical
condition.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
13. Which of these nursing actions for the patient with heart failure is appropriate for the nurse to
delegate to experienced unregulated care providers?
a. Assess for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
Unregulated care provider education varies according to the type of worker; however,
unregulated care providers are able to measure vital signs. Assessment and patient teaching
require RN education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. Which action by a newly graduated RN working on the postsurgical unit indicates that more
education about delegation and assignment is needed?
a. The nurse delegates measurement of patient oral intake and urine output to an
unregulated care provider.
b. The nurse delegates assessment of a patient’s bowel sounds to an experienced
unregulated care provider.
c. The nurse assigns an LPN/RPN to administer oral medications to several patients.
d. The nurse assigns a “float” RN from pediatrics to care for a patient with diabetes.
ANS: B
Assessment requires RN education and scope of practice and cannot be delegated to an
unregulated care provider. The other actions by the new RN are appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
15. Which of these tasks is appropriate for the registered nurse to delegate to an unregulated care
provider?
a. Perform a sterile dressing change for an infected wound.
b. Complete the patients’ initial bath.
c. Teach a patient about the effects of prescribed medications.
, d. Document patient teaching about a routine surgical procedure.
ANS: B
Unregulated care providers are able to provide personal care to patients. Patient teaching and
the initial assessment and development of the plan of care are nursing actions that require RN-
level education and scope of practice when working with patients that are not stable.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. When using the Five Steps of the Evidence-Informed Practice (EIP) Process, in which order
should the nurse construct a clinical question? (Select all that apply.)
a. Comparison of interest
b. Population of interest
c. Outcome of interest
d. Intervention of interest
e. Timeframe
ANS: A, B, C, D, E
The order of the nurse’s statements follows the PICOT format.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
,Chapter 02: Cultural Competence and Health Equity in Nursing Care
Tyerman: Lewis’s Medical-Surgical Nursing in Canada, 5th Edition
MULTIPLE CHOICE
1. Which of the following terms refer to characteristics of a group whose members share a
common social, cultural, linguistic, or religious heritage?
a.Diversity
b.Ethnicity
c.Ethnocentrism
d.Cultural imposition
ANS: B
Ethnicity is the common social, cultural, linguistic, or religious heritage of a group of people.
Diversity is a presence of persons with differences from the majority or dominant group that is
assumed to be the norm. Ethnocentrism is a tendency of individuals to believe that their way
of viewing and responding to the world is the most correct, natural, and superior one. Cultural
imposition is imposition of one person’s own cultural beliefs and practices, intentionally or
unintentionally, on another person or group of people.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
2. The nurse is caring for Indigenous patients in a community clinic setting. Which of the
following would the nurse include when developing strategies to decrease health care
disparities?
a. Improve public transportation.
b. Obtain low-cost medications.
c. Update equipment and supplies for the clinic.
d. Educate staff about Indigenous health beliefs.
ANS: D
Health care disparities are due to stereotyping, biases, and prejudice of health care providers;
the nurse can decrease these through staff education. The other strategies also may be
addressed by the nurse but will not impact health disparities.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
3. A family member of an elderly Hispanic patient admitted to the hospital tells the nurse that the
patient has traditional beliefs about health and illness. Which of the following actions is most
appropriate for the nurse in this situation?
a. Avoid asking any questions unless the patient initiates conversation.
b. Ask the patient whether it is important that cultural healers are contacted.
c. Explain the usual hospital routines for meal times, care, and family visits.
d. Obtain further information about the patient’s cultural beliefs from the daughter.
ANS: B
, Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask
whether the patient would like a visit from a cultural healer. Nurses ask key questions with
regard to language, diet, religion, and acculturation and eliciting the patient’s explanatory
model of health and illness. There is no cultural reason for the nurse to avoid asking the
patient questions, and questions may be necessary to obtain necessary health information. The
patient (rather than the daughter) should be consulted about personal cultural beliefs. The
hospital routines for meals, care, and visits should be adapted to the patient’s preferences
rather than expecting the patient to adapt to the hospital schedule.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
4. When caring for an Indigenous patient, which of the following actions is the best initial
approach in relation to eye contact for the nurse to take?
a. Avoid all eye contact with the patient.
b. Observe the patient’s use of eye contact.
c. Look directly at the patient when interacting.
d. Ask the family about the patient’s cultural beliefs.
ANS: B
Eye contact varies greatly among and within cultures so the nurse’s initial action is to assess
the patient’s use of eye contact. Although nurses are often taught to maintain direct eye
contact, patients who are Asian, Arab, or Indigenous may avoid direct eye contact and
consider direct eye contact disrespectful or aggressive. Looking directly at the patient or
avoiding eye contact may be appropriate, depending on the patient’s individual cultural
beliefs. The nurse should assess the patient, rather than asking family members about the
patient’s beliefs.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
5. A graduate nurse is assessing a newly admitted non–English-speaking Chinese patient who
complains of severe headaches. Which of the following actions by the graduate nurse would
cause the charge nurse to intervene during this assessment interview?
a. Sit down at the bedside.
b. Palpate the patient’s scalp.
c. Call for a medical interpreter.
d. Avoid eye contact with the patient.
ANS: B
Many people of Asian ethnicity believe that touching a person’s head is disrespectful; the
nurse should always ask permission before touching any patient’s head. The other actions are
appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a patient who speaks a language different from the nurse’s language
and there is no interpreter available. Which of the following actions is the most appropriate for
the nurse to implement?
a. Use specific medical terms in the Latin form.
, b. Talk loudly and slowly so that each word is clearly heard.
c. Repeat important words so that the patient recognizes their importance.
d. Use simple gestures to demonstrate meaning while talking to the patient.
ANS: D
The use of gestures will enable some information to be communicated to the patient. The
other actions will not improve communication with the patient.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
7. According to the ABC(DE)s of cultural competence, awareness of and sensitivity to cultural
values is in which of the following domains?
a. Skills domain
b. Affective domain
c. Knowledge domain
d. Behavioural domain
ANS: B
The affective domain reflects an awareness of and sensitivity to cultural values, needs, and
biases. The skills domain does not reflect an awareness of and sensitivity to cultural values,
needs, and biases. There is no skills or knowledge domain; with ABC(DE) it is affective,
behavioural, and cognitive domains as well as dynamics of difference and environment.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
8. Which of the following actions represent the best example of culturally appropriate nursing
care when caring for a newly admitted patient?
a. Have family members provide most of the patient’s personal care.
b. Maintain a personal space of at least 0.5 metres when assessing the patient.
c. Ask permission before touching a patient during the physical assessment.
d. Consider the patient’s ethnicity as the most important factor in planning care.
ANS: C
Many cultures consider it disrespectful to touch a patient without asking permission, so asking
a patient for permission is always culturally appropriate. The other actions may be appropriate
for some patients but are not appropriate across all cultural groups or for all individual
patients.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
9. While talking with the nursing supervisor, a staff nurse expresses frustration that an
Indigenous patient always has several family members at the bedside. Which of the following
actions is the most appropriate action for the nursing supervisor in this situation?
a. Remind the nurse that family support is important to this family and patient.
b. Have the nurse explain to the family that too many visitors will tire the patient.
c. Suggest that the nurse ask family members to leave the room during patient care.
d. Ask about the nurse’s personal beliefs about family support during hospitalization.
ANS: D
,
,
, Evaluation consists of determining whether the desired patient outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
9. Which of the following would the nurse perform during the assessment phase of the nursing
process?
a. Obtains data with which to diagnose patient problems.
b. Uses patient data to develop priority nursing diagnoses.
c. Teaches interventions to relieve patient health problems.
d. Assists the patient to identify realistic outcomes to health problems.
ANS: A
During the assessment phase, the nurse gathers information about the patient. The other
responses are examples of the intervention, diagnosis, and planning phases of the nursing
process.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
10. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to insufficient sense of control
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
a patient’s response to a health problem that can be treated by nursing. The use of a medical
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
uses the defining characteristics as the etiology.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
11. Which of the following includes the components required for a complete nursing diagnosis
statement?
a. A problem and the suggested patient goals or outcomes
b. A problem, its cause, and objective data that support the problem
c. A problem with all its possible causes and the planned interventions
d. A problem with its etiology and the signs and symptoms of the problem
ANS: D
The PES format is used when writing nursing diagnoses. The subjective, as well as objective,
data should be included in the defining characteristics. Interventions and outcomes are not
included in the nursing diagnosis statement.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
,12. Which of the following refers to a situation that results in unintended harm to the patient and
is related to the care or services provided rather than the patient’s medical condition?
a. Negligence
b. Adverse event
c. Incident report
d. Nonmaleficence
ANS: B
An adverse event is an event that results in unintended harm to the patient and is related to the
care or services provided to the patient rather than to the patient’s underlying medical
condition.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
13. Which of these nursing actions for the patient with heart failure is appropriate for the nurse to
delegate to experienced unregulated care providers?
a. Assess for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
Unregulated care provider education varies according to the type of worker; however,
unregulated care providers are able to measure vital signs. Assessment and patient teaching
require RN education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. Which action by a newly graduated RN working on the postsurgical unit indicates that more
education about delegation and assignment is needed?
a. The nurse delegates measurement of patient oral intake and urine output to an
unregulated care provider.
b. The nurse delegates assessment of a patient’s bowel sounds to an experienced
unregulated care provider.
c. The nurse assigns an LPN/RPN to administer oral medications to several patients.
d. The nurse assigns a “float” RN from pediatrics to care for a patient with diabetes.
ANS: B
Assessment requires RN education and scope of practice and cannot be delegated to an
unregulated care provider. The other actions by the new RN are appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
15. Which of these tasks is appropriate for the registered nurse to delegate to an unregulated care
provider?
a. Perform a sterile dressing change for an infected wound.
b. Complete the patients’ initial bath.
c. Teach a patient about the effects of prescribed medications.
, d. Document patient teaching about a routine surgical procedure.
ANS: B
Unregulated care providers are able to provide personal care to patients. Patient teaching and
the initial assessment and development of the plan of care are nursing actions that require RN-
level education and scope of practice when working with patients that are not stable.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. When using the Five Steps of the Evidence-Informed Practice (EIP) Process, in which order
should the nurse construct a clinical question? (Select all that apply.)
a. Comparison of interest
b. Population of interest
c. Outcome of interest
d. Intervention of interest
e. Timeframe
ANS: A, B, C, D, E
The order of the nurse’s statements follows the PICOT format.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
,Chapter 02: Cultural Competence and Health Equity in Nursing Care
Tyerman: Lewis’s Medical-Surgical Nursing in Canada, 5th Edition
MULTIPLE CHOICE
1. Which of the following terms refer to characteristics of a group whose members share a
common social, cultural, linguistic, or religious heritage?
a.Diversity
b.Ethnicity
c.Ethnocentrism
d.Cultural imposition
ANS: B
Ethnicity is the common social, cultural, linguistic, or religious heritage of a group of people.
Diversity is a presence of persons with differences from the majority or dominant group that is
assumed to be the norm. Ethnocentrism is a tendency of individuals to believe that their way
of viewing and responding to the world is the most correct, natural, and superior one. Cultural
imposition is imposition of one person’s own cultural beliefs and practices, intentionally or
unintentionally, on another person or group of people.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
2. The nurse is caring for Indigenous patients in a community clinic setting. Which of the
following would the nurse include when developing strategies to decrease health care
disparities?
a. Improve public transportation.
b. Obtain low-cost medications.
c. Update equipment and supplies for the clinic.
d. Educate staff about Indigenous health beliefs.
ANS: D
Health care disparities are due to stereotyping, biases, and prejudice of health care providers;
the nurse can decrease these through staff education. The other strategies also may be
addressed by the nurse but will not impact health disparities.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
3. A family member of an elderly Hispanic patient admitted to the hospital tells the nurse that the
patient has traditional beliefs about health and illness. Which of the following actions is most
appropriate for the nurse in this situation?
a. Avoid asking any questions unless the patient initiates conversation.
b. Ask the patient whether it is important that cultural healers are contacted.
c. Explain the usual hospital routines for meal times, care, and family visits.
d. Obtain further information about the patient’s cultural beliefs from the daughter.
ANS: B
, Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask
whether the patient would like a visit from a cultural healer. Nurses ask key questions with
regard to language, diet, religion, and acculturation and eliciting the patient’s explanatory
model of health and illness. There is no cultural reason for the nurse to avoid asking the
patient questions, and questions may be necessary to obtain necessary health information. The
patient (rather than the daughter) should be consulted about personal cultural beliefs. The
hospital routines for meals, care, and visits should be adapted to the patient’s preferences
rather than expecting the patient to adapt to the hospital schedule.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
4. When caring for an Indigenous patient, which of the following actions is the best initial
approach in relation to eye contact for the nurse to take?
a. Avoid all eye contact with the patient.
b. Observe the patient’s use of eye contact.
c. Look directly at the patient when interacting.
d. Ask the family about the patient’s cultural beliefs.
ANS: B
Eye contact varies greatly among and within cultures so the nurse’s initial action is to assess
the patient’s use of eye contact. Although nurses are often taught to maintain direct eye
contact, patients who are Asian, Arab, or Indigenous may avoid direct eye contact and
consider direct eye contact disrespectful or aggressive. Looking directly at the patient or
avoiding eye contact may be appropriate, depending on the patient’s individual cultural
beliefs. The nurse should assess the patient, rather than asking family members about the
patient’s beliefs.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
5. A graduate nurse is assessing a newly admitted non–English-speaking Chinese patient who
complains of severe headaches. Which of the following actions by the graduate nurse would
cause the charge nurse to intervene during this assessment interview?
a. Sit down at the bedside.
b. Palpate the patient’s scalp.
c. Call for a medical interpreter.
d. Avoid eye contact with the patient.
ANS: B
Many people of Asian ethnicity believe that touching a person’s head is disrespectful; the
nurse should always ask permission before touching any patient’s head. The other actions are
appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a patient who speaks a language different from the nurse’s language
and there is no interpreter available. Which of the following actions is the most appropriate for
the nurse to implement?
a. Use specific medical terms in the Latin form.
, b. Talk loudly and slowly so that each word is clearly heard.
c. Repeat important words so that the patient recognizes their importance.
d. Use simple gestures to demonstrate meaning while talking to the patient.
ANS: D
The use of gestures will enable some information to be communicated to the patient. The
other actions will not improve communication with the patient.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
7. According to the ABC(DE)s of cultural competence, awareness of and sensitivity to cultural
values is in which of the following domains?
a. Skills domain
b. Affective domain
c. Knowledge domain
d. Behavioural domain
ANS: B
The affective domain reflects an awareness of and sensitivity to cultural values, needs, and
biases. The skills domain does not reflect an awareness of and sensitivity to cultural values,
needs, and biases. There is no skills or knowledge domain; with ABC(DE) it is affective,
behavioural, and cognitive domains as well as dynamics of difference and environment.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
8. Which of the following actions represent the best example of culturally appropriate nursing
care when caring for a newly admitted patient?
a. Have family members provide most of the patient’s personal care.
b. Maintain a personal space of at least 0.5 metres when assessing the patient.
c. Ask permission before touching a patient during the physical assessment.
d. Consider the patient’s ethnicity as the most important factor in planning care.
ANS: C
Many cultures consider it disrespectful to touch a patient without asking permission, so asking
a patient for permission is always culturally appropriate. The other actions may be appropriate
for some patients but are not appropriate across all cultural groups or for all individual
patients.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
9. While talking with the nursing supervisor, a staff nurse expresses frustration that an
Indigenous patient always has several family members at the bedside. Which of the following
actions is the most appropriate action for the nursing supervisor in this situation?
a. Remind the nurse that family support is important to this family and patient.
b. Have the nurse explain to the family that too many visitors will tire the patient.
c. Suggest that the nurse ask family members to leave the room during patient care.
d. Ask about the nurse’s personal beliefs about family support during hospitalization.
ANS: D
