a client with a history of atrial fibrillation is prescribed warfarin coumadin which laboratory value is most concerning
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam Quizlet

1. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value is most concerning?

Correct answer: A

Rationale: An INR of 3.0 is most concerning in a client prescribed warfarin (Coumadin) as it indicates a high risk of bleeding, requiring immediate intervention. A high INR value suggests that the blood is taking longer to clot, putting the patient at an increased risk of hemorrhage. Prothrombin time (PT) measures how long it takes for blood to clot, but the specific value of 15 seconds is within the normal range. Hemoglobin of 10 g/dl indicates mild anemia and does not directly relate to the risk of bleeding associated with warfarin therapy. White blood cell count assesses immune function and infection risk, but it is not directly related to the anticoagulant effects of warfarin.

2. A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.

3. A client with cirrhosis is admitted with hepatic encephalopathy. Which laboratory value is most concerning?

Correct answer: A

Rationale: A serum ammonia level of 100 mcg/dl is most concerning in a client with hepatic encephalopathy. Elevated serum ammonia levels indicate significant liver dysfunction and an increased risk of worsening encephalopathy. Bilirubin level and prothrombin time are important in assessing liver function, but in the context of hepatic encephalopathy, elevated ammonia levels take precedence as they directly contribute to neurological symptoms. Serum sodium level, though important, is not the primary concern when managing hepatic encephalopathy.

4. The nurse observes an adolescent client preparing to administer a prescribed corticosteroid medication using a metered dose inhaler. What action should the nurse take?

Correct answer: A

Rationale: Corrected Rationale: Reminding the client to hold their breath after inhaling the medication is crucial as it helps ensure the medication is absorbed into the lungs. Option B is incorrect because shaking the inhaler is not directly related to the client's inhalation technique. Option C is incorrect as correct positioning of the inhaler is important but not the immediate action needed in this situation. Option D is incorrect as asking about the spacer is not the most relevant action to take at this moment.

5. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?

Correct answer: A

Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.

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