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. What is the first action to take for a patient experiencing a seizure?

A. Administer anticonvulsant medication
B. Protect the patient's head
C. Insert an oral airway
D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

3. A nurse is caring for a client who is receiving enteral nutrition via a nasogastric tube. Which of the following actions should the nurse take to reduce the risk of aspiration?

A. Position the client supine during feedings.
B. Administer the feedings over 10 minutes.
C. Elevate the head of the bed during feedings.
D. Place the client in a lateral position after feedings.

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration in clients receiving enteral feedings is to elevate the head of the bed during feedings. This position helps prevent regurgitation and aspiration of the feeding. Positioning the client supine (Choice A) increases the risk of aspiration as it promotes reflux. Administering feedings over 10 minutes (Choice B) does not directly reduce the risk of aspiration. Placing the client in a lateral position after feedings (Choice D) does not address the risk of aspiration during the feeding process.

4. A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

A. I should avoid using salt substitutes while taking this medication.
B. I should take this medication with food to prevent nausea.
C. I should increase my intake of potassium-rich foods while taking this medication.
D. I should limit my fluid intake while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.

5. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?

A. Use a 21-gauge needle for injection.
B. Inject the medication into the client's deltoid muscle.
C. Administer the medication within 5 cm (2 in) of the umbilicus.
D. Massage the injection site after administration.

Correct answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.