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. When surgery is on-going, who coordinates the activities outside, including the family?

• A. Orderly/clerk C. Circulating Nurse
• B. Nurse Supervisor D. Anesthesiologist
• 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. Which assessment finding indicates effective treatment for hyperemesis gravidarum?

• A. The client's glucose is within the normal range.
• B. The client ate 80% of their breakfast tray.
• C. There is no protein in the client's urine.
• D. The client's blood pressure is 145/75 mmHg.

Correct answer: B

Rationale: Improved appetite and food intake is an indication of effective treatment.

4. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hours.
• B. Obtain the client’s electrolyte levels every 4 hours.
• C. Keep the client’s head elevated at 15° during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hours.

Correct answer: D

Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

5. Which of the following is NOT required on a food label or nutrition facts panel?

• A. Nutrition facts panel
• B. Ingredients in descending order by weight
• C. The % RDA of ALL the vitamins and minerals in the product
• D. Essential warnings, such as common allergies

Correct answer: C

Rationale: According to food labeling regulations, every food label or nutrition facts panel must include a nutrition facts panel, list of ingredients in descending order by weight, and essential warnings such as common allergies. However, it is not mandatory to list the % Recommended Daily Allowance (RDA) of ALL the vitamins and minerals in the product. Only certain vitamins and minerals, deemed significant to public health, are required to be listed. Therefore, the notion that the % RDA of ALL vitamins and minerals must be displayed is incorrect. Choices A, B, and D are required elements on a food label, making them incorrect answers.

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