how should a nurse monitor for bleeding in a patient on warfarin

ATI RN

ATI RN Exit Exam 2023

1. How should bleeding in a patient on warfarin be monitored?

A. Monitor INR levels
B. Monitor hemoglobin levels
C. Monitor potassium levels
D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.

2. A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?

A. Blood urea nitrogen (BUN) 25 mg/dL
B. Serum creatinine 1.5 mg/dL
C. Serum glucose 110 mg/dL
D. White blood cell (WBC) count 5,000/mm3

Correct answer: A

Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.

3. A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?

A. Encourage the client to increase dietary fiber.
B. Maintain the client on a low-residue diet.
C. Provide the client with frequent high-calorie snacks.
D. Encourage the client to eat a high-fiber diet.

Correct answer: B

Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.

4. How should signs of infection in a post-surgical patient be assessed?

A. Check the surgical site
B. Check the patient's vital signs
C. Monitor for fever
D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

5. A nurse is assessing a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

A. Heart rate of 62/min
B. Blood pressure of 118/78 mm Hg
C. Respiratory rate of 10/min
D. Pain rating of 4 on a scale of 0 to 10

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within normal limits and are not indicative of a potentially life-threatening complication associated with morphine therapy.