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. Which food is recommended for a client trying to increase their intake of calcium?

• A. Apples
• B. Yogurt
• C. Chicken
• D. Pasta

Correct answer: B

Rationale: Yogurt is high in calcium, which is essential for bone health.

3. A condition that often progresses to become type 2 diabetes mellitus is:

• A. type 1 diabetes mellitus
• B. high blood pressure
• C. chronic pancreatitis
• D. impaired glucose tolerance

Correct answer: D

Rationale: Impaired glucose tolerance is a pre-diabetic state characterized by higher than normal blood sugar levels. It is often associated with insulin resistance and can progress to type 2 diabetes mellitus. Type 1 diabetes mellitus (Choice A) is an autoimmune condition where the body attacks insulin-producing cells, leading to a lack of insulin production. High blood pressure (Choice B) and chronic pancreatitis (Choice C) are not directly linked to the progression to type 2 diabetes mellitus.

4. What is the most effective way to limit the number of microorganisms in the hospital?

• A. Using strict aseptic technique in all procedures
• B. Wearing a mask and gown when caring for all patients with communicable diseases
• C. Sterilizing all instruments
• D. Handwashing

Correct answer: A

Rationale: The most effective way to limit the number of microorganisms in the hospital is by using strict aseptic technique in all procedures. This approach ensures that the risk of introducing harmful microorganisms into the hospital environment or patients is minimized. Choice B, wearing a mask and gown when caring for patients with communicable diseases, is important but not as comprehensive as using aseptic technique in all procedures. Sterilizing all instruments (Choice C) is crucial for preventing infections but may not address all avenues of microorganism transmission. Handwashing (Choice D) is a fundamental practice in infection control but alone may not be as effective as utilizing aseptic techniques in all procedures to limit microorganisms in the hospital.

5. After bronchoscopy, the nurse's priority is to check which of the following before feeding?

• A. Gag reflex
• B. Wearing off of anesthesia
• C. Swallowing reflex
• D. Peristalsis

Correct answer: A

Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.

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