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 conducting a cleansing enema, how does the nurse position the client?

• A. Right lateral position
• B. Left lateral position
• C. Right Sim's position
• D. Left Sim's position

Correct answer: B

Rationale: In preparing a patient for a cleansing enema, the nurse typically positions the patient in the left lateral position. This position allows for the best flow of the solution due to the anatomical configuration of the colon. The right lateral position, right Sim's position, and left Sim's position are not typically used for this procedure. The rationale provided initially is incorrect as it pertains to lung expansion and postural drainage, which are not relevant to a cleansing enema procedure.

3. Each statement is true of fat-soluble vitamins, except one. Which is the exception?

• A. Fairly stable to heat, such as during cooking
• B. Contain carbon
• C. Stored in the pancreas
• D. Absorbed in the intestine along with fats and lipids in food

Correct answer: C

Rationale: Fat-soluble vitamins are not stored in the pancreas; they are stored in the liver and fatty tissues. Choice A is correct as fat-soluble vitamins are fairly stable to heat. Choice B is also correct as fat-soluble vitamins contain carbon. Choice D is correct as fat-soluble vitamins are absorbed in the intestine along with fats and lipids in food.

4. Fat-soluble vitamins are different from water-soluble vitamins because the body is able to store only small amounts of fat-soluble vitamins.

• A. Both the statement and the reason are correct and related.
• B. Both the statement and the reason are correct but are not related.
• C. The statement is correct, but the reason is not correct.
• D. The statement is not correct, but the reason is correct.

Correct answer: C

Rationale: The statement is correct, but the reason is not correct. A major difference between fat-soluble and water-soluble vitamins is that the body is able to store larger amounts of fat-soluble vitamins. Vitamins A and D are stored for long periods; therefore, minor shortages might not be identified until drastic depletion has occurred. Observable signs and symptoms of a dietary deficiency are often not identified until they are in an advanced state. Water-soluble vitamins, on the other hand, are not stored in the body and are excreted in the urine if taken in excess, making it harder to reach toxic levels.

5. 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.

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