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. The nurse knows that after receiving the blood from the blood bank, it should be administered within:

• A. 1 hour
• B. 2 hours
• C. 4 hours
• D. 6 hours

Correct answer: D

Rationale: Blood transfusions need to be administered promptly after receiving the blood from the blood bank to ensure patient safety and effectiveness. Waiting too long can lead to complications such as bacterial growth in the blood product, which can be harmful when infused. Administering the blood within 6 hours is crucial to prevent such risks. Choices A, B, and C are incorrect because waiting for 1, 2, or 4 hours respectively can increase the likelihood of complications associated with delayed transfusion.

3. Nurse DMLM is correct in identifying the correct sequence of events during abdominal assessment if she identifies which of the following?

• A. Inspection, Auscultation, Percussion, Palpation
• B. Inspection, Percussion, Palpation, Auscultation
• C. Inspection, Palpation, Percussion, Auscultation
• D. Inspection, Auscultation, Palpation, Percussion

Correct answer: D

Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation, Percussion, Palpation. Start with Inspection to observe any visible abnormalities, followed by Auscultation to listen for bowel sounds, then Percussion to assess the density of underlying structures, and finally Palpation to feel for any tenderness or masses. Choices A, B, and C have the incorrect sequence of assessment techniques.

4. What is the most important concern immediately after a myocardial infarction?

• A. Reducing cholesterol intake
• B. Allowing cardiac rest for healing
• C. Reducing saturated fat intake
• D. Eating several small meals each day

Correct answer: B

Rationale: Immediately after a myocardial infarction, the primary concern is to allow the heart to rest and heal to prevent further damage. This is why choice B is the correct answer. While choices A, C, and D might be a part of the long-term management plan following a myocardial infarction, they are not the immediate priority. Reducing cholesterol and saturated fat intake, as well as adjusting eating habits can help prevent future heart issues, but do not directly contribute to the immediate recovery post-myocardial infarction.

5. Which mental health disorder can lead to the erosion of lingual enamel, enlarged parotid glands, palatal bruising, and dentinal hypersensitivity?

• A. Bulimia
• B. Anorexia nervosa
• C. Depression
• D. Schizophrenia

Correct answer: A

Rationale: The correct answer is A: Bulimia. Bulimia involves repeated episodes of binge eating followed by purging, which can lead to the erosion of lingual enamel, enlarged parotid glands, palatal bruising, and dentinal hypersensitivity. This behavior exposes the teeth to stomach acid during purging, causing damage to the enamel. Choices B, C, and D are incorrect because these conditions are not typically associated with the specific oral health issues mentioned in the question.

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