Nursing Elites

1. What is considered fast breathing in a 13-month-old child if the respiratory rate (RR) exceeds which value?

• A. 40 breaths per minute
• B. 50 breaths per minute
• C. 60 breaths per minute
• D. 30 breaths per minute

Correct answer: C

Rationale: In the context of pediatric care, a respiratory rate of more than 60 breaths per minute in a child aged 13 months is considered fast breathing, hence option 'C' is correct. Options 'A', 'B', and 'D' are incorrect as they do not meet the specified criteria for fast breathing in a 13-month-old. Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, including monitoring respiratory rates, to ensure that interventions are appropriately targeted and outcomes are optimized.

2. Which of the following has the greatest effect on an increase in body weight?

• A. Carbohydrate intake
• B. Protein intake
• C. Fat intake
• D. Total kilocalories

Correct answer: D

Rationale: Total kilocalories have the greatest effect on body weight as they represent the overall energy intake from all macronutrients combined. While the consumption of specific macronutrients like carbohydrates, proteins, and fats can affect weight management, the total calories consumed play the most significant role in determining body weight. Therefore, choices A, B, and C are incorrect as they focus on individual macronutrients rather than the overall energy balance provided by total kilocalories.

3. An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:

• A. Risk for injury directed to self
• B. Risk for injury directed to others
• C. Impaired nutrition less than body requirements
• D. Ineffective individual coping

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. Which of the following foods should be avoided by patients experiencing xerostomia, except one? Which is the exception?

• A. Saltines
• B. Salsa
• C. Alcohol
• D. Dill pickles

Correct answer: D

Rationale: The correct answer is Dill pickles. Unlike the other choices, which can exacerbate xerostomia due to their dry or irritating nature, dill pickles, being tart and sour, can actually help stimulate saliva flow, which is beneficial for patients with xerostomia. Saltines, salsa, and alcohol are all known to contribute to dry mouth and should generally be avoided by individuals experiencing xerostomia.

5. 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.

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