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 provides discharge instructions to a client about the food items that interact with warfarin effectiveness. Which food item indicates that the teaching was effective?

• A. Cauliflower
• B. Zucchini
• C. Green beans
• D. Broccoli

Correct answer: A

Rationale: Cauliflower is high in vitamin K, which can interact with warfarin.

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 physiologic role does magnesium play in the body?

• A. Blood clotting, transmission of nerve impulses, muscle contraction and relaxation
• B. Calcium homeostasis, structural integrity of heart muscle
• C. No known metabolic function, caries-preventing properties
• D. ATP energy release; metabolism of fats, carbohydrates, proteins; regulates acid-base balance

Correct answer: B

Rationale: The correct answer is B. Magnesium plays an important role in maintaining calcium homeostasis and preventing skeletal abnormalities. It is involved in more than 300 enzymatic reactions, including energy metabolism, insulin activity, and glucose use. Magnesium is vital to the structural integrity of heart muscle and other muscles and nerves. While magnesium does play a role in blood clotting, nerve impulses, muscle contraction, relaxation, ATP energy release, and metabolism of fats, carbohydrates, proteins, the primary physiologic role of magnesium in the body is related to calcium homeostasis and maintaining the structural integrity of the heart muscle. Choice A is incorrect because it includes functions of magnesium, but they are not its primary physiologic role. Choice C is incorrect as magnesium has several known metabolic functions. Choice D is incorrect because although magnesium is involved in ATP energy release and metabolism, its primary role is related to calcium homeostasis and structural integrity of muscle.

5. Which nutrient is most closely associated with the prevention of neural tube defects in a developing fetus for a woman planning to become pregnant?

• A. Calcium
• B. Folate
• C. Vitamin A
• D. Choline

Correct answer: B

Rationale: The correct answer is folate. Folate, also known as Vitamin B9, is vital for the prevention of neural tube defects in the developing fetus. It is primarily responsible for the creation and repair of DNA, which is essential during rapid growth stages such as pregnancy. While nutrients like calcium, vitamin A, and choline are important for pregnancy, they are not as directly linked to preventing neural tube defects as folate. Calcium is crucial for the baby's bone and teeth development. Vitamin A is essential for vision, immune function, and cellular growth. Choline supports brain development and neural functioning. However, none of these nutrients have the same direct impact on preventing neural tube defects as folate.

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