what nursing diagnosis would be most appropriate for a patient with heart failure
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Nursing Elites

ATI RN

ATI Proctored Nutrition Exam

1. What nursing diagnosis would be most appropriate for a patient with heart failure?

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. Cariogenic foods and beverages, which are fermentable carbohydrates that can be metabolized by oral bacteria, reduce salivary pH to what critical level?

Correct answer: B

Rationale: Cariogenic foods and beverages lower the pH level in the mouth to below 5.5. This is a critical threshold, as it is the point at which enamel begins to demineralize, increasing the risk of dental caries. Therefore, options 'A', 'C', and 'D' are incorrect. Although a pH level of 5, as suggested by option 'A', would indeed lead to demineralization, it's not the threshold value. The pH levels suggested by options 'C' and 'D' (6 and 6.5, respectively) are higher than the critical value of 5.5, which means they would not initiate enamel demineralization and the subsequent risk of dental caries.

3. Muscle weakness due to wasting would most likely be evaluated by which test?

Correct answer: C

Rationale: Handgrip strength is a reliable test to assess muscle function and detect muscle weakness due to wasting. It is often used to identify conditions like sarcopenia in clinical settings. Options A, B, and D are not suitable for evaluating muscle weakness. Food intake recall does not directly measure muscle function, skinfold thickness assesses body fat but not muscle strength, and red blood cell levels are unrelated to muscle wasting.

4. While a team effort is necessary in the operating room (OR) for efficient and quality patient care delivery, the number of people in the room should be limited for infection control purposes. Which roles comprise this team?

Correct answer: B

Rationale: The roles typically present in an operating room team include the surgeon, assistants (which may include an assistant surgeon), scrub nurse, circulating nurse, and anesthesiologist. These roles are directly involved in the operation and patient care. Choice B is correct. Choice A includes a radiologist and an orderly, who are not typically part of the immediate surgical team in the OR. Choice C includes a pathologist, who usually works in a laboratory outside of the OR. Choice D includes an intern, who may or may not be part of the team, depending on the specific circumstances and hospital policy. These explanations make choices A, C, and D incorrect.

5. A nurse is providing nutritional information to a client with osteoporosis. Which food should the nurse recommend as being the highest in calcium?

Correct answer: B

Rationale: Canned salmon with bones is high in calcium.

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