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 teaching a client about preparing low-fat meals. The nurse should include that which of the following oils contains saturated fat?

• A. Corn
• B. Olive
• C. Canola
• D. Coconut

Correct answer: D

Rationale: Coconut oil contains a high amount of saturated fat, which can increase LDL cholesterol levels and the risk of heart disease. Olive, corn, and canola oils are primarily unsaturated fats, which are considered heart-healthy fats. Olive oil, in particular, is rich in monounsaturated fats, while corn and canola oils are good sources of polyunsaturated fats. Therefore, the correct answer is Coconut because it contains saturated fat, unlike the other options.

3. A nurse is providing teaching to the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include?

• A. Sliced bananas
• B. Raw celery
• C. Peanut butter
• D. Grapes

Correct answer: A

Rationale: The correct answer is sliced bananas. Bananas are a good choice for toddlers as they are easy to chew, rich in potassium, and generally well-tolerated. Raw celery (Choice B) may pose a choking hazard due to its fibrous nature. Peanut butter (Choice C) should be avoided as it can also be a choking hazard and may cause an allergic reaction in some children. Grapes (Choice D) are a choking hazard for toddlers due to their size and shape, so they should be cut into smaller pieces or avoided altogether.

4. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

5. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?

• A. Tell her family that probably she can’t hear them
• B. Talk loudly so that Wendy can hear you
• C. Tell her family who are in the room not to talk
• D. Speak softly then hold her hands gently

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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