Nursing Elites

1. A client is prescribed digoxin for heart failure. Which of the following should the nurse monitor to evaluate the effectiveness of the medication?

• A. Respiratory rate
• B. Blood pressure
• C. Apical pulse
• D. Urine output

Correct answer: C

Rationale: The correct answer is C: Apical pulse. Digoxin's primary effect is to strengthen the force of the heart's contractions and slow the heart rate. Monitoring the apical pulse is crucial in evaluating the effectiveness of digoxin as it helps assess the medication's impact on the heart's function. Option A, respiratory rate, is not directly related to digoxin's mechanism of action and is not the most appropriate parameter to monitor for this medication. Option B, blood pressure, while important, may not be as sensitive as the apical pulse in assessing the effectiveness of digoxin. Option D, urine output, is more indicative of kidney function and fluid balance, rather than the direct effectiveness of digoxin in heart failure.

2. A nurse is reviewing the laboratory results for a client who has end-stage liver disease. Which of the following findings should the nurse expect?

• A. Elevated albumin
• B. Elevated ammonia
• C. Decreased total bilirubin
• D. Decreased prothrombin time

Correct answer: B

Rationale: In end-stage liver disease, the liver's inability to convert ammonia into urea leads to elevated ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Therefore, the correct answer is B. Elevated albumin (Choice A) is not typically seen in end-stage liver disease as liver dysfunction often leads to decreased albumin levels. Decreased total bilirubin (Choice C) is unlikely in end-stage liver disease, as bilirubin levels tend to be elevated due to impaired liver function. Decreased prothrombin time (Choice D) is also not expected in end-stage liver disease, as impaired liver function results in prolonged prothrombin time.

3. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

• A. I will make sure my medications are enteric-coated
• B. My stoma will drain liquid continuously
• C. I will change my pouch system every two weeks
• D. My stoma size will stay the same after it heals

Correct answer: B

Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.

4. A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?

• A. The possibility of pregnancy within 4 weeks
• B. Client allergy to strawberry
• C. Client history of genital herpes
• D. The possibility of overseas travel in the next month

Correct answer: A

Rationale: The correct answer is A. The MMR vaccine is contraindicated in pregnant women due to the risk of fetal harm. It is recommended that women avoid becoming pregnant for at least 4 weeks after receiving the vaccine. Choice B, client allergy to strawberry, is not a contraindication for the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication for the MMR vaccine.

5. While in the cafeteria, a nurse overhears two APs discussing a hospitalized patient. What action should the nurse take?

• A. Report the incident to the supervisor.
• B. Join the conversation to intervene.
• C. Quietly tell the APs that this is not appropriate.
• D. Ignore the conversation.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to choose option C: 'Quietly tell the APs that this is not appropriate.' The nurse should immediately and discreetly address the situation, reminding the APs that discussing patient information in public areas violates confidentiality. Reporting the incident to the supervisor (option A) may be necessary if the behavior continues. Joining the conversation to intervene (option B) may escalate the situation and compromise patient confidentiality. Ignoring the conversation (option D) does not address the violation or prevent it from recurring.

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