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. Which of the following are the primary bacteria involved in the initiation of dental caries?

• A. Streptococcus mutans and Lactobacillus species
• B. Salmonella and Listeria species
• C. Streptococcus, Lactobacillus, and Salmonella species
• D. Listeria, Botulinum species, and Escherichia coli

Correct answer: A

Rationale: The correct answer is A: Streptococcus mutans and Lactobacillus species. These bacteria are primarily responsible for initiating dental caries by fermenting carbohydrates and producing acids that demineralize enamel. Choice B, Salmonella and Listeria species, are not the primary bacteria involved in dental caries. Choice C includes Salmonella which is not a primary culprit in dental caries. Choice D lists Listeria, Botulinum species, and Escherichia coli, none of which are the primary bacteria associated with initiating dental caries.

3. A nurse is discussing denture care with the partner of a client who is unable to perform oral hygiene. Which of the following should be included in the discussion?

• A. Floss dentures as part of daily cleaning.
• B. Wipe dentures before storing them in a dry container at night.
• C. Wrap gloved fingers with gauze to remove dentures.
• D. Use a washcloth to clean the denture surfaces.

Correct answer: C

Rationale: The correct answer is C: 'Wrap gloved fingers with gauze to remove dentures.' This method provides a safe and effective way to remove dentures without causing damage. Choice A is incorrect because flossing dentures is not recommended. Choice B is incorrect as it suggests wiping dentures and storing them dry, which is not the best practice. Choice D is incorrect because using a washcloth may not effectively clean all denture surfaces.

4. A nurse is caring for four clients. The nurse should plan to administer total parenteral nutrition for which of the following clients?

• A. A client who is postoperative following a laminectomy and is receiving IV PCA
• B. A client who has dysphagia and does not recognize his family
• C. A client who has COPD and is going home with oxygen
• D. A client who has colon cancer and will undergo a hemicolectomy

Correct answer: D

Rationale: Total parenteral nutrition (TPN) is essential for clients undergoing significant surgical procedures like a hemicolectomy to ensure they receive adequate nutrition when oral intake is not possible. Choices A, B, and C do not typically require TPN. Choice A is managing postoperative pain with IV PCA, choice B is likely to need alternative feeding methods due to dysphagia, and choice C is going home with oxygen for COPD management, which does not directly relate to the need for TPN.

5. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

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