Nursing Elites

1. This vaccine content is derived from RNA recombinants.

• A. Measles C. Hepatitis B vaccines
• B. Tetanus toxoids D. DPT
• C.
• D.

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

2. Lynn is an older adult who lives alone and has requested advice on how to eat a nutritious diet as cheaply as possible. One useful, practical tip for Lynn might be to _____.

• A. buy just a few pieces of fresh fruit at a time, in different stages of ripeness
• B. choose small boxes of frozen vegetables instead of large bags
• C. purchase pre-sliced or shredded cheese rather than whole pieces
• D. avoid buying certain foods in bulk, such as beans or dried legumes

Correct answer: A

Rationale: Buying a few pieces of fresh fruit at different stages of ripeness ensures that Lynn will have ripe fruit available over several days, reducing waste and cost. Choice B focuses on frozen vegetables but doesn't address the variety and ripeness factor like Choice A. Choice C is about cheese, which may not be as essential for a nutritious diet compared to fresh fruit. Choice D suggests avoiding certain foods in bulk, which might not be as relevant for maintaining a nutritious diet economically as the strategy in Choice A.

3. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

4. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?

• A. inhibition of the parasympathetic reflex
• B. weakness of sphincter muscles of anus
• C. loss of tone of the smooth muscles of the colon
• D. decreased ability to absorb fluids in the lower intestines

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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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