Nursing Elites

1. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

• A. Hold the medication
• B. Administer the digoxin
• C. Notify the healthcare provider
• D. Recheck the apical rate in 1 hour

Correct answer: B

Rationale: An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly used to treat heart failure by increasing the strength and efficiency of the heart's contractions. Since the heart rate is within the normal range, there is no need to hold the medication or notify the healthcare provider. Rechecking the apical rate in an hour is unnecessary as the heart rate is not alarming. Therefore, the appropriate nursing action is to administer the digoxin.

2. The nurse is planning to provide education about foods containing thiamine to a group of clients. Which food high in thiamine should the nurse include?

• A. Fish
• B. Pork
• C. Beef
• D. Eggs

Correct answer: B

Rationale: The correct answer is B: Pork. Pork is high in thiamine, which is important for preventing thiamine deficiency. Thiamine, also known as Vitamin B1, is essential for the body's metabolism and proper functioning of the nervous system. While fish, beef, and eggs are nutritious foods, they do not contain as high levels of thiamine as pork does. Therefore, when educating clients about thiamine-rich foods, pork would be the most appropriate choice.

3. After attempting suicide by taking 200 acetaminophen (Tylenol) tablets, a client is transferred from the emergency department to the locked psychiatric unit. The client is now awake and alert but refuses to speak with the nurse. In this situation, what is the nurse’s first priority?

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.

4. Identifying the strengths and weaknesses in the plan of nursing care is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: A

Rationale: The correct answer is A: Evaluation. Evaluation in nursing care involves assessing the effectiveness of the care plan, identifying strengths, weaknesses, and areas for improvement. This step helps ensure that the patient's needs are being met appropriately. Planning (choice B) involves developing the care plan based on the assessment data. Implementation (choice C) is the step where the care plan is put into action. Assessment (choice D) is the initial step in the nursing process that involves collecting and analyzing data about the patient's health status.

5. Where do most peptic ulcers occur?

• A. Esophagus
• B. Stomach
• C. Duodenum
• D. Jejunum

Correct answer: C

Rationale: Most peptic ulcers occur in the duodenum, particularly in cases of duodenal ulcers. The correct answer is the duodenum because it is the most common site for peptic ulcers to develop. Peptic ulcers rarely occur in the esophagus and jejunum, making choices A, B, and D incorrect.

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