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 caregiver is teaching a parent about recommended protein intake for a toddler. Which of the following food selections is equivalent to 1 oz of protein?

• A. 2 tbsp peanut butter
• B. ½ cup peas
• C. 1 slice of bread
• D. 1 scrambled egg

Correct answer: D

Rationale: One scrambled egg is equivalent to 1 oz of protein, making it a suitable choice for a toddler's diet. A ½ cup of peas (choice B) does not provide 1 oz of protein but is still a good source of protein. 2 tbsp of peanut butter (choice A) contains more than 1 oz of protein. 1 slice of bread (choice C) typically provides less protein than 1 oz.

3. When assessing older adult clients for malnutrition at an adult day care center, which risk factors should the nurse consider?

• A. Dental problems
• B. Depression
• C. Both A and B
• D. Ability to prepare meals

Correct answer: C

Rationale: The correct answer is C: Both A and B. Dental problems and depression are both significant risk factors for malnutrition in older adults. Dental problems can lead to difficulty in chewing and swallowing, resulting in reduced food intake. On the other hand, depression can cause changes in appetite and decreased interest in eating, which can also contribute to malnutrition. Although the ability to prepare meals is important, it is not specifically identified as a risk factor for malnutrition within the context of this question. Therefore, choices A and B are the most appropriate answers.

4. Which foods increase iron absorption when consumed with nonheme iron? (SATA)

• A. Kiwi
• B. Strawberries
• C. Coffee
• D. A, B

Correct answer: D

Rationale: Kiwi and strawberries are high in vitamin C, which increases iron absorption.

5. In monitoring the patient in PACU, the nurse correctly identifies that checking the patient's vital signs is done every:

• A. 1 hour
• B. 5 minutes
• C. 15 minutes
• D. 30 minutes

Correct answer: A

Rationale: Correct Answer: A - Vital signs monitoring in the PACU (Post-Anesthesia Care Unit) is typically done every hour to closely monitor the patient's condition during the immediate postoperative period. This frequency allows the nurse to promptly identify any changes in the patient's vital signs and intervene as necessary. Choice B (5 minutes) is too frequent for routine vital signs monitoring in the PACU and may not allow for a comprehensive assessment of the patient's stability. Choice C (15 minutes) and Choice D (30 minutes) are also not in line with the standard practice of vital signs monitoring in the PACU, which is typically hourly.

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