Nursing Elites

1. 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.

2. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

• A. NPO until dysphagia subsides
• B. Supplements via nasogastric tube
• C. Initiation of total parenteral nutrition
• D. Soft residue diet

Correct answer: B

Rationale: In the scenario of severe dysphagia following a CVA, the client may have difficulty swallowing and require alternative nutritional support. Providing supplements via a nasogastric tube allows for the delivery of essential nutrients directly into the stomach, bypassing the swallowing difficulties. NPO (nothing by mouth) until dysphagia subsides may be too restrictive for the client's nutritional needs. Initiation of total parenteral nutrition is usually reserved for cases where enteral feeding is not possible or contraindicated. A soft residue diet may not be suitable for a client experiencing severe dysphagia.

3. A nurse is planning a menu for a client with a folic acid deficiency anemia. Which food should the nurse recommend that is high in folate?

• A. 4 slices of roast beef
• B. ½ cup of asparagus
• C. 1 cup part-skim mozzarella cheese
• D. ¼ cup of olives

Correct answer: B

Rationale: The correct answer is B: ½ cup of asparagus. Asparagus is high in folate, making it a suitable recommendation for clients with folic acid deficiency anemia. Folate is essential in the production of red blood cells, which is crucial in managing anemia. Choices A, C, and D do not contain as much folate as asparagus and are not the best options for addressing a folic acid deficiency anemia.

4. What gastrointestinal side effects are associated with antisecretory drugs such as proton pump inhibitors?

• A. Nausea and vomiting
• B. Gastroparesis
• C. Dumping syndrome
• D. Flatulence

Correct answer: A

Rationale: Proton pump inhibitors (PPIs) are a type of antisecretory drug that can cause nausea and vomiting by altering stomach acid production. These are common side effects associated with PPIs. Gastroparesis (B) is a condition that affects the stomach muscles and prevents proper stomach emptying; it is not a side effect of PPIs. Dumping syndrome (C) is a group of symptoms that can occur after having part of your stomach removed and is not a side effect of PPIs. While some people might experience flatulence (D) when taking PPIs, it is not as commonly associated with these drugs as the effects of nausea and vomiting.

5. A client scheduled for hysterosalpingography needs health teaching before the procedure. The nurse is correct in telling the patient that:

• A. She needs to void prior to the procedure
• B. A full bladder is needed prior to the procedure
• C. Painful sensation is felt as the needle is inserted
• D. Flushing sensation is felt as the dye in injected

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.

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