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. This vaccine content is derived from RNA recombinants.

• A. Measles C. Hepatitis B vaccines
• B. Tetanus toxoids D. DPT
• C.
• D.

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

3. A client receiving chemotherapy treatments tells the nurse, 'I feel so nauseated after my treatments.' Which of the following instructions should the nurse provide the client?

• A. Eat common foods that are served cold.
• B. Sip fluids slowly throughout the day.
• C. Sit up for 1 hr after eating meals.
• D. All of the Above

Correct answer: D

Rationale: The correct answer is D, 'All of the Above.' Common foods served cold, sipping fluids slowly throughout the day, and sitting up for 1 hr after eating meals can help manage nausea associated with chemotherapy. Eating common foods served cold can be easier on the stomach, sipping fluids slowly can prevent overwhelming the digestive system, and sitting up after meals can aid digestion. Choices A, B, and C all contribute to alleviating nausea and are appropriate instructions for the client.

4. The counting of sponges is done by the Surgeon together with the:

• A. Circulating nurse
• B. Scrub nurse
• C. Assistant surgeon
• D. Nurse supervisor

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.

5. Match amylase with its digestive action:

• A. breaks down carbs
• B. breaks down proteins
• C. breaks down lipids
• D. helps fat digestion

Correct answer: A

Rationale: The correct answer is A: 'breaks down carbs.' Amylase is an enzyme that specifically targets carbohydrates, breaking them down into simpler sugars like maltose. This process aids in the digestion of carbohydrates in the human body. Choices B, C, and D are incorrect because amylase does not break down proteins, lipids, or directly aid fat digestion. Proteins are broken down by proteases, lipids are broken down by lipases, and fat digestion is primarily assisted by bile salts and lipases in the small intestine.

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