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. What is the first step in decontamination?

• A. Immediately applying a chemical decontamination foam to the area of contamination
• B. Thoroughly washing and rinsing the patient with soap and water
• C. Immediately applying personal protective equipment
• D. Removing the patient's clothing and jewelry, then rinsing the patient with water

Correct answer: D

Rationale: The correct first step in decontamination is to remove the patient's clothing and jewelry to prevent further exposure and then rinse the patient with water. This helps to eliminate any contaminants on the patient's body. Choice A is incorrect because applying a chemical decontamination foam should come after removing clothing. Choice B is incorrect as washing and rinsing the patient should follow the removal of clothing. Choice C is incorrect as personal protective equipment should be worn by the individual performing the decontamination, not applied to the patient.

3. A client newly diagnosed with hypertension is receiving teaching about the Mediterranean diet from a nurse. Which of the following statements by the client indicates a need for further teaching?

• A. I will limit my intake of red meat to twice weekly.
• B. I can have dairy in moderate portions daily.
• C. I can have fish two times a week.
• D. I can drink wine in moderation.

Correct answer: D

Rationale: The correct answer is D. Patients with hypertension should be advised to limit alcohol consumption, including wine, to help manage their blood pressure. Choices A, B, and C are all consistent with the Mediterranean diet and are appropriate for a client with hypertension. Reducing red meat intake, consuming dairy in moderate portions, and having fish regularly align with the principles of this heart-healthy eating pattern.

4. A client is being taught by a nurse about adding more fiber to the diet. Which of the following foods has the highest fiber content?

• A. 1 cup cooked sweet potato
• B. 1 slice rye toast
• C. 1 cup raw watermelon
• D. 1 oz cashews

Correct answer: D

Rationale: The correct answer is D, 1 oz of cashews. Cashews have a higher fiber content compared to sweet potato, rye toast, and watermelon. While sweet potatoes and rye toast contain fiber, cashews have a higher concentration, making them a better choice for increasing fiber intake. Watermelon, on the other hand, is low in fiber compared to the other options provided.

5. A 52-year-old male patient recently required surgery for the removal of a large calcium oxalate stone. To prevent further stone formation, the nurse advises against drinking?

• A. apple juice
• B. tea
• C. orange juice
• D. coffee

Correct answer: B

Rationale: Tea contains oxalates, which can contribute to the formation of calcium oxalate stones; therefore, patients prone to kidney stones should avoid excessive tea consumption.

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