Nursing Elites

1. Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?

• A. 15 minutes
• B. 30 minutes
• C. 1 hour
• D. 5 minutes

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. 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.

3. As Leda’s nurse, you plan to set up an emergency equipment at her beside following thyroidectomy. You should include:

• A. An airway and rebreathing tube
• B. A tracheostomy set and oxygen
• C. A crush cart with bed board
• D. Two ampules of sodium bicarbonate

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.

4. Which food would benefit an anemic patient by increasing their intake?

• A. Beef
• B. Apples
• C. White bread
• D. Fish

Correct answer: A

Rationale: An anemic patient would benefit from increasing their intake of beef. Beef is an excellent source of heme iron, which is critical for treating anemia. Heme iron is absorbed more readily by the body compared to non-heme iron found in plant-based foods. Apples and white bread, while healthy, do not contain significant amounts of heme iron. Fish, although it does contain iron, it's non-heme iron, which is not as efficiently absorbed by the body as heme iron, hence less effective in treating anemia.

5. A community health nurse is conducting a class on what to expect during pregnancy. What instruction should the nurse include on weight gain?

• A. Failure to obtain the required weight gain during pregnancy will increase the risk of preterm birth.
• B. An obese client should not gain as much weight as a client with a normal body mass index.
• C. A client with a normal body mass index should plan on gaining 50 pounds.
• D. Clients do not need to eat for two when they are pregnant.

Correct answer: A

Rationale: Adequate weight gain during pregnancy is essential as failure to obtain the required weight gain can increase the risk of preterm birth. Choice B is incorrect because it is important for obese clients to gain an appropriate amount of weight during pregnancy, not the same as those with a normal body mass index. Choice C is incorrect as gaining 50 pounds for a client with a normal body mass index is excessive. Choice D is incorrect as the common saying 'eating for two' during pregnancy is a misconception; pregnant individuals do not need to double their caloric intake.

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