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. Instruction on health promotion regarding urinary elimination is important. Which would you include?

• A. Hold urine as long as possible before emptying the bladder to strengthen the sphincter muscles
• B. If a burning sensation is experienced while voiding, drink water
• C. After urination, wipe from the anal area towards the pubis
• D. Tell the client to empty the bladder at each voiding

Correct answer: D

Rationale: The correct answer is to instruct the client to empty the bladder at each voiding. This is essential to prevent urinary retention and reduce the risk of urinary tract infections. Choice A is incorrect because holding urine for prolonged periods can lead to urinary retention and increase the risk of infections. Choice B is incorrect as pineapple juice can exacerbate a burning sensation due to its acidity; the correct approach is to drink water to dilute the urine. Choice C is incorrect as wiping from the anal area towards the pubis can introduce bacteria into the urinary tract, potentially causing infections.

3. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

• A. Amount of food and fluid taken during the last meal before treatment
• B. Respiratory rate, breath sounds, and location of congestion
• C. Teaching the client's relatives to perform the procedure
• D. Doctor's order regarding position restrictions and client's tolerance for lying flat

Correct answer: B

Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.

4. What dietary factor raises triglyceride levels?

• A. high refined carbohydrate intake
• B. low soluble fiber intake
• C. high iron intake
• D. low fat intake

Correct answer: A

Rationale: The correct answer is A: high refined carbohydrate intake. High intake of refined carbohydrates, such as sugars and white flour, can lead to elevated triglyceride levels, increasing the risk of cardiovascular disease. Choice B, low soluble fiber intake, is incorrect because soluble fiber actually helps lower triglyceride levels. Choice C, high iron intake, is incorrect as iron intake is not directly linked to raising triglyceride levels. Choice D, low fat intake, is also incorrect as not all fats raise triglyceride levels; it depends on the type of fat consumed.

5. After surgery Leda develops peripheral numbness, tingling and muscle twitching and spasm. What would you anticipate to administer?

• A. Magnesium sulfate C. Potassium iodide
• B. Calcium gluconate D. Potassium chloride
• C.
• D.

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

Similar Questions