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. After cleaning the abrasions and applying antiseptic, the nurse applies a cold compress to the swollen ankle as ordered by the physician. This statement shows that the nurse has a correct understanding of the use of a cold compress:

• A. Cold compress reduces blood viscosity in the affected area
• B. It is safer to apply than a hot compress
• C. Cold compress prevents edema and reduces pain
• D. It eliminates toxic waste products due to vasodilation

Correct answer: C

Rationale: The correct understanding of using a cold compress includes knowing that it helps prevent edema and reduces pain. Cold application constricts blood vessels, reducing blood flow to the area, which helps decrease swelling and pain. Choices A, B, and D are incorrect because cold compresses do not directly affect blood viscosity, safety compared to hot compresses, or eliminate toxic waste products due to vasodilation. It is essential for nurses to have a clear understanding of the rationale behind interventions to provide effective patient care.

3. What type of drug would most likely be given to a patient following a myocardial infarction?

• A. antiemetic
• B. anticoagulant
• C. anticonvulsant
• D. antibiotic

Correct answer: B

Rationale: Anticoagulants are the most suitable choice for a patient following a myocardial infarction. These medications are essential in preventing further blood clots from forming in the arteries, reducing the risk of complications such as strokes or recurrent heart attacks. Antiemetics are used to control nausea and vomiting, not directly related to myocardial infarction. Anticonvulsants are used to manage seizures, not typically indicated after a heart attack. Antibiotics are prescribed to treat bacterial infections, not routinely given after a myocardial infarction.

4. What is the initial major sign of acute renal failure?

• A. Oliguria
• B. Hematuria
• C. Proteinuria
• D. Glycosuria

Correct answer: A

Rationale: Oliguria, or reduced urine output, is often the initial major sign of acute renal failure. This reduction in urine output indicates that the kidneys are not functioning properly. Hematuria (blood in urine), proteinuria (presence of protein in urine), and glycosuria (presence of glucose in urine) are not typically the initial major signs of acute renal failure. While they may be present in certain conditions, oliguria is the most common and critical indicator of acute renal failure.

5. What should be recommended to help prevent early childhood caries (ECC) in infants?

• A. Avoid giving the infant nighttime bottles
• B. Have the infant drink pasteurized skim milk
• C. Feed the infant iron-rich foods
• D. Give the infant fruit juice to drink

Correct answer: A

Rationale: The correct answer is 'A: Avoid giving the infant nighttime bottles' because prolonged exposure to sugars in milk during the night can lead to caries. Options 'B: Have the infant drink pasteurized skim milk' and 'D: Give the infant fruit juice to drink' are not recommended as they contain sugars that can cause cavities, especially in infants. Option 'C: Feed the infant iron-rich foods' is incorrect because while a balanced diet is important, iron-rich foods do not directly prevent caries development.

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