Nursing Elites

1. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Albumin increases the circulating blood volume, which helps to reduce ascites and improve hemodynamics in clients with portal hypertension. Choice A is incorrect because salt-poor albumin is not primarily administered to provide nutrients. Choice B is incorrect because the main purpose of administering albumin is not to increase protein stores but to address fluid shifts. Choice D is incorrect because administering albumin does not divert blood flow away from the liver temporarily; instead, it helps improve blood volume and circulation.

2. Determining nursing care priorities is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the identified patient needs, establishing goals, and developing a plan of care. Evaluation involves assessing the effectiveness of the care provided, implementation is the phase where the care plan is carried out, and assessment is the initial step of collecting data to identify the patient's needs. Therefore, in the context of determining nursing care priorities, the correct step is Planning (choice B).

3. An important part of nutrition therapy for patients with cystic fibrosis is:

• A. A low-fat diet to prevent steatorrhea
• B. A low-sodium diet to normalize fluid status
• C. A high-fiber diet to normalize bowel function
• D. Pancreatic enzyme replacement therapy to help digestion

Correct answer: D

Rationale: The correct answer is D: Pancreatic enzyme replacement therapy to help digestion. In cystic fibrosis, pancreatic insufficiency leads to the malabsorption of nutrients, making it essential for patients to take pancreatic enzymes to aid in digestion. Options A, B, and C are incorrect because a low-fat diet may not provide adequate nutrition for cystic fibrosis patients, a low-sodium diet is not the primary focus of nutrition therapy in cystic fibrosis, and a high-fiber diet may exacerbate gastrointestinal symptoms due to malabsorption.

4. Enteral feedings may be appropriate for patients with:

• A. Acute cholecystitis
• B. Hepatic encephalopathy
• C. Ulcerative colitis in remission
• D. Acute exacerbation of Crohn’s disease

Correct answer: D

Rationale: Enteral feedings are commonly utilized for patients experiencing acute exacerbations of Crohn’s disease to provide necessary nutrition and rest the bowel. Choices A, B, and C are incorrect because enteral feedings are not typically indicated for acute cholecystitis, hepatic encephalopathy, or ulcerative colitis in remission.

5. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

• A. Second intercostal space, right sternal border
• B. Erb’s point
• C. Second intercostal space, left sternal border
• D. Fourth intercostal space, left sternal border

Correct answer: A

Rationale: The correct answer is A: Second intercostal space, right sternal border. The aortic valve is best auscultated at the second intercostal space, right sternal border, where the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as they are not the recommended anatomical positions for auscultating the murmur of aortic stenosis.

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