Culture & Spirituality
1. A nurse is providing culturally competent care. Which actions demonstrate appropriate practice?
Select all that apply.
A. Asking the patient how they prefer to be addressed
B. Using a trained medical interpreter
C. Assuming cultural preferences based on ethnicity
D. Encouraging patients to abandon traditional remedies
E. Assessing beliefs that influence healthcare decisions
F. Incorporating safe cultural practices into care
Correct Answers: A, B, E, F
Rationales:
A nurse is teaching a patient about long-term heart-healthy eating habits. Which meal selections show correct understanding? Select all that apply.
A. Baked salmon, brown rice, steamed broccoli
B. Turkey sandwich on whole-grain bread with apple slices
C. Fried chicken, biscuits, and cream gravy
D. Oatmeal topped with berries and a side of low-fat yogurt
E. Ham, boxed macaroni and cheese, and canned green beans
F. Grilled chicken salad with olive oil vinaigrette
Correct answers: A, B, D, F
Rationale:
A is right because it includes lean protein with beneficial fats, a whole grain, and vegetables. This supports healthy eating habits and reduces excess saturated fat.
B is right because whole grains, lean poultry, and fruit fit balanced nutrition principles. It is much better than processed or fried convenience foods.
C is wrong because frying and cream gravy greatly increase saturated fat and calories. This type of meal does not reflect proper everyday eating habits.
D is right because oatmeal and berries support fiber intake, while low-fat yogurt adds protein and calcium without excessive saturated fat.
E is wrong because ham and boxed foods are often high in sodium and processed fats. Canned vegetables may also be high in sodium unless labeled otherwise.
F is right because this is nutrient-dense and balanced, with lean protein, vegetables, and a healthier fat source in the dressing.
Which patient has the highest risk for developing a urinary tract infection?
A. A postoperative patient with an indwelling catheter in place for 4 days
B. A young adult who drinks 2 liters of water daily
C. A patient who ambulates to the bathroom every 2 hours
D. A patient with stress incontinence who wears pads
Correct answer: A
Rationale:
A is right because indwelling urinary catheters are one of the strongest risk factors for UTI, especially as duration increases. This is a classic priority risk factor.
B is wrong because adequate hydration generally lowers UTI risk by encouraging regular urine flow.
C is wrong because regular emptying helps reduce urine stasis and bacterial growth.
D is wrong because stress incontinence alone does not create the same degree of infection risk as an indwelling catheter, though skin issues may still need attention.
16.
Which complication is the nurse’s greatest concern in a patient with ongoing diarrhea?
A. Urinary retention
B. Dehydration and electrolyte imbalance
C. Fecal impaction
D. Increased appetite
Correct answer: B
Rationale:
A is wrong because diarrhea does not usually cause urinary retention; fluid losses would more likely reduce urine output if dehydration develops.
B is right because repeated loose stools can rapidly cause fluid and electrolyte losses, especially in older adults or ill patients.
C is wrong because fecal impaction is more associated with constipation, though liquid seepage around an impaction can be confusing in some cases.
D is wrong because increased appetite is not the primary danger associated with diarrhea.
Correct answer: B
Rationale:
A is wrong because diarrhea does not usually cause urinary retention; fluid losses would more likely reduce urine output if dehydration develops.
B is right because repeated loose stools can rapidly cause fluid and electrolyte losses, especially in older adults or ill patients.
C is wrong because fecal impaction is more associated with constipation, though liquid seepage around an impaction can be confusing in some cases.
D is wrong because increased appetite is not the primary danger associated with diarrhea.
20.
Which action best reflects the nurse’s role as described in the ANA Code of Ethics?
A. Prioritizing institutional convenience over patient preferences
B. Advocating for the patient’s safety, dignity, and rights
C. Deferring all ethical concerns to the provider
D. Sharing confidential information with family to reduce their anxiety
Correct answer: B
Rationale:
A is wrong because nursing ethics centers the patient, not organizational convenience.
B is right because advocacy, dignity, safety, and respect for patient rights are central ethical nursing responsibilities.
C is wrong because nurses are independently accountable for recognizing and responding to ethical concerns.
D is wrong because confidentiality cannot be broken just to reassure family members.
2. Which questions are appropriate during a spiritual assessment?
A. “How do your beliefs influence your healthcare decisions?”
B. “Do you have spiritual practices you would like to continue?”
C. “What religion are you?”
D. “Would you like to see a chaplain?”
E. “Are your beliefs important during illness?”
F. “You attend church regularly, correct?”
Correct Answers: A, B, D, E
Rationales:
7. A nurse is preparing a tray for a patient on a full liquid diet. Which items are appropriate? Select all that apply.
A. Vanilla pudding
B. Strained cream soup
C. Applesauce
D. Ice cream
E. Scrambled eggs
F. Yogurt without fruit chunks
Correct answers: A, B, D, F
Rationale:
A is right because pudding is allowed on a full liquid diet; it is smooth and requires little to no chewing.
B is right because strained cream soup fits a full liquid diet as long as chunks are removed.
C is wrong because applesauce is usually classified with soft foods, not full liquids, since it does not fully meet the liquid consistency standard used in most nursing diet questions.
D is right because ice cream counts as a full liquid item unless a specific restriction says otherwise.
E is wrong because scrambled eggs are soft, but they are not liquid. Students often miss this because they are easy to chew, but “easy to chew” is not the same as “full liquid.”
F is right because smooth yogurt without chunks is generally acceptable on a full liquid diet.
A provider orders a clean-catch urine specimen for culture. Which instruction by the nurse is best?
A. “Collect the first urine that comes out into the cup.”
B. “Clean the area, begin voiding, and then collect the middle portion of urine.”
C. “Collect urine from the toilet hat after you finish voiding.”
D. “Save your first morning urine from any container at home.”
Correct answer: B
Rationale:
A is wrong because the initial stream may flush surface organisms into the specimen and contaminate the culture.
B is right because the clean-catch midstream method reduces contamination and gives a more accurate sample for culture.
C is wrong because urine collected from a toilet hat is more likely to be contaminated and is not appropriate for culture.
D is wrong because specimen technique and handling matter; using “any container at home” does not maintain sterile or clean-catch standards.
17. Which nursing action is most appropriate for a patient with suspected paralytic ileus?
A. Encourage a high-fiber meal and ambulation only
B. Offer a laxative and warm prune juice
C. Withhold oral intake as prescribed and assess bowel sounds and distention
D. Begin bowel training after breakfast each day
Correct answer: C
Rationale:
A is wrong because paralytic ileus is not simple constipation; adding fiber to a nonfunctioning bowel can worsen discomfort and is not appropriate.
B is wrong because laxatives and prune juice are not the initial answer to absent bowel motility and may be harmful depending on the cause.
C is right because ileus means bowel motility is reduced or absent. Patients often need bowel rest, ongoing assessment, and treatment of the underlying cause.
D is wrong because bowel training is more appropriate for chronic elimination issues, not acute ileus.
21.
Which elements are essential for valid informed consent? Select all that apply.
A. The patient has decision-making capacity
B. The decision is voluntary
C. The procedure is explained, including risks and alternatives
D. The nurse personally performs the procedure explanation for the provider
E. The patient demonstrates understanding
F. Consent is obtained after preoperative sedation is given
Correct answers: A, B, C, E
Rationale:
A is right because the patient must be capable of making the decision.
B is right because coercion invalidates consent.
C is right because informed consent requires disclosure of what is being done, its risks, benefits, alternatives, and what may happen if the patient refuses.
D is wrong because the provider performing the procedure is responsible for the explanation; the nurse may witness the signature and reinforce teaching but does not replace the provider’s duty.
E is right because the patient must meaningfully understand the information, not just sign a paper.
F is wrong because sedation may impair capacity and voluntariness.
3. A patient defers all decisions to her husband. What is the nurse’s priority action?
A. Request consent from the husband
B. Notify the provider
C. Ask the patient privately whom she prefers to make decisions
D. Encourage independent decision-making
Correct Answer: C
Rationale: This respects autonomy while honoring cultural preferences. Consent must come from the patient unless legally delegated.
8. A patient taking warfarin asks which lunch choice is best. Which meal should the nurse recommend?
A. Spinach salad with broccoli and green tea
B. Kale smoothie and avocado toast
C. Turkey sandwich on white bread with applesauce and carrots
D. Mixed greens salad with Brussels sprouts
Correct answer: C
Rationale:
A is wrong because spinach and broccoli are high in vitamin K, which can reduce the effectiveness of warfarin if intake is inconsistent.
B is wrong because kale is especially high in vitamin K. The issue is not that the patient can never have vitamin K, but that intake must stay consistent. On exams, the best answer is usually the lower-vitamin-K choice.
C is right because this meal avoids the highest vitamin K foods listed and is the safest option among the choices. It also reflects that the nurse should help the patient choose appropriate foods rather than just giving vague warnings.
D is wrong because mixed greens and Brussels sprouts are both foods with significant vitamin K content.
13. A nurse is teaching a patient with stress incontinence. Which interventions should the nurse include? Select all that apply.
A. Perform pelvic floor muscle exercises regularly
B. Reduce excess body weight if indicated
C. Increase caffeine intake to improve bladder emptying
D. Use scheduled toileting or timed voiding
E. Stop smoking if the patient has a chronic cough
F. Restrict all oral fluids to reduce leakage
Correct answers: A, B, D, E
Rationale:
A is right because pelvic floor exercises strengthen the structures that help prevent leakage with coughing, sneezing, or exertion.
B is right because excess body weight increases intra-abdominal pressure and can worsen stress incontinence.
C is wrong because caffeine can irritate the bladder and worsen urgency and leakage patterns.
D is right because timed voiding can help reduce episodes by preventing an overly full bladder.
E is right because chronic coughing increases intra-abdominal pressure and can worsen stress incontinence.
F is wrong because severe fluid restriction can concentrate urine, irritate the bladder, and create dehydration. Patients may need smart fluid timing, not total restriction.
18.
32 | SATA | Elimination | Ileostomy dietary teaching | 3 | 39 | Application | Planning | Basic Care & Comfort | Patient-Centered Care
A nurse teaches a patient with a new ileostomy about diet. Which statements by the nurse are appropriate? Select all that apply.
A. “Drink plenty of fluids each day.”
B. “Chew your food thoroughly.”
C. “Expect stool to be fully formed like before surgery.”
D. “Introduce high-fiber foods carefully.”
E. “Foods such as nuts, popcorn, and raw vegetables may increase blockage risk.”
F. “A sudden drop in output with cramping should be reported.”
Correct answers: A, B, D, E, F
Rationale:
A is right because ileostomy patients lose more fluid and are at greater risk for dehydration.
B is right because good chewing helps reduce the risk of food blockage.
C is wrong because ileostomy output is usually liquid to semiliquid, not fully formed.
D is right because high-fiber foods may need to be reintroduced slowly to judge tolerance.
E is right because bulky, stringy, or poorly digested foods may obstruct the stoma.
F is right because decreased output with cramping can signal blockage, which needs prompt evaluation.
Correct answers: A, B, D, E, F
Rationale:
A is right because ileostomy patients lose more fluid and are at greater risk for dehydration.
B is right because good chewing helps reduce the risk of food blockage.
C is wrong because ileostomy output is usually liquid to semiliquid, not fully formed.
D is right because high-fiber foods may need to be reintroduced slowly to judge tolerance.
E is right because bulky, stringy, or poorly digested foods may obstruct the stoma.
F is right because decreased output with cramping can signal blockage, which needs prompt evaluation.
22.
A competent patient refuses an injection. The nurse says, “You have no choice,” and administers it anyway. Which legal violation occurred?
A. Assault only
B. Battery only
C. Both assault and battery
D. Negligence
Correct answer: C
Rationale:
A is wrong because assault refers to the threat or action causing fear of unwanted touching, but here the touching also occurred.
B is incomplete because battery did occur, but the threatening statement also created assault.
C is right because the threat or coercive statement supports assault, and the actual unwanted injection supports battery.
D is wrong because negligence is failure to use reasonable care; this scenario is more specifically intentional tort behavior.
4. A patient states, “God is punishing me.” Which nursing diagnosis is most appropriate?
A. Anxiety
B. Spiritual distress
C. Ineffective coping
D. Hopelessness
Correct Answer: B
Rationale: Spiritual distress involves disruption in belief systems that provide meaning and support.
Which patients are at increased risk for malnutrition? Select all that apply.
A. An older adult who lives alone and has difficulty shopping
B. A patient with painful swallowing after radiation therapy
C. A patient with depression who reports no appetite
D. A healthy college athlete with no food insecurity and stable weight
E. A postoperative patient with prolonged nausea
F. A patient with poorly fitting dentures
Correct answers: A, B, C, E, F
Rationale:
A is right because isolation, limited mobility, and limited access to food can all decrease intake and increase malnutrition risk in older adults.
B is right because painful swallowing makes eating difficult and often causes patients to avoid adequate intake.
C is right because depression commonly reduces appetite, motivation, and meal preparation.
D is wrong because nothing in the option suggests nutrition risk. This is the distractor meant to see whether you can separate general categories of people from actual risk factors.
E is right because prolonged nausea reduces oral intake and may lead to nutrient deficits during recovery.
F is right because chewing problems often lead patients to avoid nutrient-dense foods like meats, fruits, and vegetables.
14. Which instructions should the nurse give for a 24-hour urine collection? Select all that apply.
A. Discard the first void at the start time
B. Save every void after the start time, including the last void at the end time
C. If one specimen is missed, continue the collection and simply document it
D. Keep the urine container on ice or refrigerated if required by policy
E. Place toilet tissue in the specimen container to absorb odor
F. Notify the nurse if any urine is accidentally discarded
Correct answers: A, B, D, F
Rationale:
A is right because the collection begins after the first void is discarded. That marks the start time.
B is right because every urine specimen after that must be saved, including the final specimen exactly at the end of the collection period.
C is wrong because missing one specimen usually invalidates the test and often requires restarting the collection.
D is right because many 24-hour urine collections require cooling to preserve specimen integrity.
E is wrong because nothing except urine should enter the collection container.
F is right because the nurse must know if the sample is incomplete so the provider and lab are not given misleading results.
19.
A nurse is evaluating teaching for a patient with a new sigmoid colostomy. Which patient statement shows correct understanding?
A. “My stool should usually be loose and watery.”
B. “My stool will likely be more formed than stool from an ascending colostomy.”
C. “I should expect continuous drainage of digestive enzymes.”
D. “I will have the highest risk of severe dehydration from stool losses.”
Correct answer: B
Rationale:
A is wrong because watery stool is more typical of an ileostomy or more proximal colostomy, not a sigmoid colostomy.
B is right because the farther along the bowel the ostomy is placed, the more water has been absorbed, so sigmoid colostomy stool is often more formed.
C is wrong because continuous enzyme-rich drainage is not the classic expectation for a sigmoid colostomy.
D is wrong because dehydration risk is usually much greater with ileostomies than with sigmoid colostomies.
23.
Which examples are forms of advance care planning or directives the nurse should recognize? Select all that apply.
A. Living will
B. Durable power of attorney for healthcare
C. Provider orders for life-sustaining treatment, where used
D. A patient’s unsigned verbal wish from 10 years ago relayed by a neighbor
E. Do-not-resuscitate order
F. The patient’s last will and testament about property distribution
Correct answers: A, B, C, E
Rationale:
A is right because a living will states treatment preferences for future incapacity.
B is right because it designates a person to make healthcare decisions if the patient cannot.
C is right because these medical orders translate wishes into actionable clinical instructions in many settings.
D is wrong because this is unreliable, informal, and not a recognized directive by itself in this form.
E is right because a DNR is a recognized medical order related to resuscitation decisions.
F is wrong because a last will and testament deals with property and assets after death, not healthcare decisions.
5. A patient refuses a blood transfusion due to religious beliefs. Which actions should the nurse take?
Select all that apply.
A. Respect the refusal
B. Notify the provider
C. Ensure informed refusal is documented
D. Encourage the family to persuade the patient
E. Explore alternative treatments
F. Seek a court order immediately
Correct Answers: A, B, C, E
Rationales:
10. A patient receiving nasogastric tube feedings reports nausea and fullness. The nurse notes abdominal distention. Which action is priority?
A. Increase the rate so the ordered volume is completed on time
B. Stop the feeding temporarily and assess for intolerance according to policy
C. Place the patient flat to improve comfort
D. Add fruit juice to the formula to stimulate bowel activity
Correct answer: B
Rationale:
A is wrong because the symptoms suggest feeding intolerance. Increasing the rate would likely worsen nausea, distention, and possibly aspiration risk.
B is right because the patient is showing signs of intolerance. The nurse should pause the feeding as indicated by policy, assess the patient, verify tube placement and other relevant findings according to facility protocol, and notify the provider as needed.
C is wrong because lying the patient flat increases aspiration risk. Tube-fed patients should generally have the head of bed elevated unless contraindicated.
D is wrong because adding anything to formula without an order is unsafe and could alter osmolarity or clog the tube.
Correct answer: B
Rationale:
A is wrong because the symptoms suggest feeding intolerance. Increasing the rate would likely worsen nausea, distention, and possibly aspiration risk.
B is right because the patient is showing signs of intolerance. The nurse should pause the feeding as indicated by policy, assess the patient, verify tube placement and other relevant findings according to facility protocol, and notify the provider as needed.
C is wrong because lying the patient flat increases aspiration risk. Tube-fed patients should generally have the head of bed elevated unless contraindicated.
D is wrong because adding anything to formula without an order is unsafe and could alter osmolarity or clog the tube.
15.
Which situation best justifies insertion of an indwelling urinary catheter?
A. A patient with functional incontinence who dislikes using the bedside commode
B. A patient in shock who requires precise hourly urine output measurement
C. A patient who is embarrassed by frequent bedpan use
D. A postoperative patient who is stable and can ambulate with assistance
Correct answer: B
Rationale:
A is wrong because convenience is not an appropriate indication for an indwelling catheter.
B is right because critically ill patients who need exact hourly output are appropriate candidates for catheterization. In shock, urine output is an important marker of perfusion and organ function.
C is wrong because embarrassment does not justify the infection risk of catheter placement.
D is wrong because if the patient can ambulate with assistance and void normally, catheterization should generally be avoided.
19.
Which nursing actions are appropriate when caring for a patient with a new colostomy? Select all that apply.
A. Assess the stoma color for pink to red, moist tissue
B. Measure the stoma regularly during the postoperative period
C. Clean the peristomal skin gently and dry it well
D. Apply the pouch opening exactly the same size as the base of the stoma with no space
E. Empty the pouch when it is about one-third to one-half full
F. Report a dusky or black stoma promptly
Correct answers: A, B, C, E, F
Rationale:
A is right because a healthy stoma is usually pink to red and moist. That reflects adequate perfusion.
B is right because stoma size changes, especially early after surgery when swelling decreases. Equipment fit must be updated accordingly.
C is right because peristomal skin care helps prevent breakdown from moisture and stool.
D is wrong because the opening should fit closely but not constrict the stoma; having absolutely no space can injure tissue, while too much space exposes skin to stool. This option is too rigidly worded to be the best answer.
E is right because overfilled pouches are more likely to leak and pull on the skin barrier.
F is right because dusky, purple, or black coloring may indicate impaired blood supply and requires immediate attention.
24.
Which nursing actions are appropriate during postmortem care? Select all that apply.
A. Provide privacy and treat the body with dignity
B. Follow facility policy and cultural or religious practices when possible
C. Remove all tubes and lines immediately in every death
D. Place identification according to policy
E. Support family viewing if desired and appropriate
F. Recognize that autopsy, organ donation, or medical examiner cases may require special handling
Correct answers: A, B, D, E, F
Rationale:
A is right because respect for dignity continues after death.
B is right because postmortem care should reflect policy while also honoring cultural or religious needs when possible.
C is wrong because some situations require lines or tubes to remain in place, such as autopsy, coroner, or organ donation cases.
D is right because accurate identification is a required safety and legal step.
E is right because family support remains important after death.
F is right because special circumstances change routine care steps and must be recognized.