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. When surgery is on-going, who coordinates the activities outside, including the family?

• A. Orderly/clerk C. Circulating Nurse
• B. Nurse Supervisor D. Anesthesiologist
• C.
• D.

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.

3. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hours.
• B. Obtain the client’s electrolyte levels every 4 hours.
• C. Keep the client’s head elevated at 15° during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hours.

Correct answer: D

Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

4. A client who is breastfeeding is being taught diet modification by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should drink an 8-ounce glass of water each time my baby nurses.
• B. I should take a 1500-milligram iron supplement daily.
• C. I can eat a 2500-calorie daily diet to lose 1 lb per week.
• D. I can eat ounces of swordfish daily.

Correct answer: A

Rationale: The correct answer is A because drinking an 8-ounce glass of water each time the baby nurses helps maintain hydration and support milk production. Choice B is incorrect as the need for iron supplementation should be discussed with a healthcare provider. Choice C is incorrect as a 2500-calorie diet is not typically recommended for weight loss during breastfeeding. Choice D is incorrect as consuming high levels of swordfish is not advisable due to its mercury content, which can be harmful to the baby.

5. Which of the following best describes Primary Nursing?

• A. Assigning a nurse to lead a team of registered nurses in the care of a patient from admission to discharge
• B. Assigning a nurse to perform administrative tasks in a healthcare setting
• C. Assigning a nurse to provide medical treatment without supervision
• D. Assigning a nurse to be the main caregiver responsible for coordinating all aspects of care for a group of patients

Correct answer: A

Rationale: Primary Nursing involves assigning a dedicated nurse to lead a team of registered nurses in the care of a patient from admission to discharge. This approach ensures continuity and personalized care. Choices B and C are incorrect as they do not accurately describe Primary Nursing. Choice D is incorrect as it refers to a different care delivery model.

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