Nursing Elites

1. The breakdown in teamwork is often times a failure in:

• A. Electricity
• B. Inadequate supply
• C. Leg work
• D. Communication

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.

2. 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.

3. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

• A. Increase the irrigating solution flow rate when abdominal cramps is felt
• B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
• C. Position client in semi-Fowler
• D. Hang the solution 18 inches above the stoma

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. A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?

• A. A client with a weight of 128 lb and height of 70 inches
• B. A client with a weight of 150 lb and height of 68 inches
• C. A client with a weight of 200 lb and height of 72 inches
• D. A client with a weight of 133 lb and height of 60 inches

Correct answer: A

Rationale: To determine a healthy BMI, we need to calculate it using the formula: BMI = weight (lbs) / height^2 (inches) x 703. For choice A, BMI = 128 / (70 x 70) x 703 = 18.38, which falls within the healthy BMI range of 18.5-24.9. Therefore, choice A is correct. Choices B, C, and D have BMIs of 22.8, 27.1, and 26.1, respectively, which are outside the healthy range. Thus, choices B, C, and D are incorrect.

5. A client who follows the dietary laws of Orthodox Judaism is being cared for by a nurse. Which of the following meal choices should the nurse request for the client?

• A. Turkey and cheese sandwich
• B. Spaghetti with tomato sauce
• C. Pork chop and applesauce
• D. Scrambled eggs and bacon

Correct answer: B

Rationale: The correct meal choice for a client following the dietary laws of Orthodox Judaism is 'Spaghetti with tomato sauce.' Orthodox Judaism prohibits mixing meat and dairy and consuming pork. The other choices - 'Turkey and cheese sandwich' (mixing meat and dairy), 'Pork chop and applesauce' (contains pork), and 'Scrambled eggs and bacon' (mixing meat and dairy) - do not adhere to the kosher dietary laws.

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