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. In taking the client’s blood pressure, the nurse should position the client’s arm:

• A. At the level of the heart
• B. Slightly above the level of the heart
• C. At the 5th intercostals space midclavicular line
• D. Below the level of the heart

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

3. Name 4 of the 12 discussed groups at risk for nutritional deficiencies.

• A. Elderly
• B. Low income
• C. Vegans
• D. Chronic disease, alcoholics

Correct answer: A

Rationale: The correct answer is A: Elderly. The other choices provided, low income, vegans, and chronic disease, alcoholics, are also at risk for nutritional deficiencies but the question specifically asks for 4 groups out of the 12 discussed. The 12 groups at risk for nutritional deficiencies include the elderly, low income individuals, vegans, chronic disease, alcoholics, smokers, periods of growth, individuals with medical conditions, physical stress, physiological stress, those on polypharmacy, and those with inadequate intake. The question focuses on identifying 4 out of these 12 groups, making 'Elderly' the correct choice.

4. In a patient with chronic kidney disease, which dietary modification is recommended?

• A. Increase protein intake
• B. Reduce potassium intake
• C. Increase sodium intake
• D. Reduce fiber intake

Correct answer: B

Rationale: Reducing potassium intake is important for patients with chronic kidney disease to prevent hyperkalemia.

5. A vegan patient might be at risk for deficiency in which of the following nutrients?

• A. Vitamin B12
• B. Vitamin C
• C. Carbohydrates
• D. Fiber

Correct answer: A

Rationale: The correct answer is Vitamin B12. Vitamin B12 is primarily found in animal products, so individuals following a vegan diet are at risk of deficiency as they do not consume these sources. Vitamin C, Carbohydrates, and Fiber are not specifically at risk for deficiency in vegan diets as they can be obtained from plant-based sources.

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