Nursing Elites

1. Baby John develops hyperbilirubinemia. What is a method used to treat hyperbilirubinemia in a newborn?

• A. Keeping infants in a warm and dark environment
• B. Administration of cardiovascular stimulant
• C. Gentle exercise to stop muscle breakdown
• D. Early feeding to speed passage of meconium

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. A nurse in a long-term care facility is developing strategies to promote increased food intake for an older adult client. Which of the following interventions should the nurse implement?

• A. Offer sugar substitutes to increase the client’s appetite.
• B. Provide opportunities to eat three large meals per day.
• C. Provide entertainment while the client is eating.
• D. Offer finger foods at mealtime.

Correct answer: D

Rationale: The correct intervention for promoting increased food intake for an older adult client is to offer finger foods at mealtime. Finger foods are easier for older adults to manage, making eating less cumbersome and more enjoyable, which can help increase overall food intake. Providing sugar substitutes (Choice A) may not necessarily increase appetite and could have negative health effects. Eating three large meals per day (Choice B) may be overwhelming and not suitable for older adults who may prefer smaller, more frequent meals. While providing entertainment (Choice C) during meals can be beneficial in some cases, it may not directly contribute to increased food intake as effectively as offering finger foods.

3. A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?

• A. Check for gastric residual.
• B. Apply low intermittent suction.
• C. Increase the rate of the feeding.
• D. Request a higher-fat formula.

Correct answer: A

Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.

4. The most significant factor that might affect the nurse’s care for the psychiatric patient is:

• A. Nurse’s own beliefs and attitude about the mentally ill
• B. Amount of experience he has with psychiatric clients
• C. Her abilities and skill to care for the psychiatric clients
• D. Her knowledge in dealing with the psychiatric clients

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

5. What nursing diagnosis would be most appropriate for a patient with heart failure?

• A. risk for infection
• B. fluid volume excess
• C. impaired body temperature
• D. ineffective airway clearance

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

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