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. The nurse is planning education about appropriate protein food choices for a client who has recently been prescribed a renal diet. Which protein food items should the nurse include in the education?

• A. Yogurt, seeds, and lentils
• B. Beef, bacon, and nuts
• C. Peanut butter, beans, and peas
• D. Poultry, eggs, and fish

Correct answer: D

Rationale: The correct answer is D: Poultry, eggs, and fish. These protein sources are high-quality proteins suitable for a renal diet as they provide essential amino acids without excessive amounts of potassium or phosphorus. Choice A, yogurt, seeds, and lentils, may be high in potassium and phosphorus, which could be restricted in a renal diet. Choice B, beef, bacon, and nuts, are also high in phosphorus and may not be ideal for a renal diet. Choice C, peanut butter, beans, and peas, are high in potassium and phosphorus, making them less suitable for a renal diet.

3. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone?

• A. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
• B. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24
• C. Have the registered nurse, family and doctor sign the order
• D. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours

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. The stages of grieving identified by Elizabeth Kubler-Ross are:

• A. Numbness, anger, resolution and reorganization
• B. Denial, anger, identification, depression and acceptance
• C. Anger, loneliness, depression and resolution
• D. Denial, anger, bargaining, depression and acceptance

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. People with only one arm or hand may benefit from using a ____ when eating?

• A. dish with suction cups
• B. rocker knife
• C. utensil holder
• D. flexible straw

Correct answer: B

Rationale: A rocker knife is specifically designed for individuals with limited use of one hand or arm, allowing them to cut food easily. This makes it a suitable option for people with only one arm or hand. Choice A, a dish with suction cups, may not directly aid in cutting food with one hand. Choice C, an utensil holder, is not typically used for cutting food. Choice D, a flexible straw, is more related to drinking liquids and not specifically designed to assist in cutting food one-handed.

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