Nursing Elites

1. The client is on warfarin and has an INR of 1.5. What is the nurse’s priority action?

• A. Increase the dose of warfarin.
• B. Hold the next dose of warfarin.
• C. Continue the current dose of warfarin.
• D. Monitor the client’s INR closely.

Correct answer: B

Rationale: An INR of 1.5 is below the therapeutic range for a client on warfarin, indicating that the client may be at risk of clot formation. The nurse's priority action should be to hold the next dose of warfarin to prevent further reduction of the INR. Increasing the dose could potentially lead to an increased risk of bleeding, and continuing the current dose may not be sufficient to bring the INR within the therapeutic range. Monitoring the client's INR closely is important but not the priority action in this scenario.

2. The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse’s priority action?

• A. Hold the spironolactone and notify the healthcare provider.
• B. Administer potassium supplements.
• C. Continue the spironolactone as ordered.
• D. Increase the dose of spironolactone.

Correct answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels. Therefore, the priority action is to withhold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further management. Option B is incorrect because administering potassium supplements would worsen the hyperkalemia. Option C is incorrect as continuing spironolactone can lead to a further increase in potassium levels. Option D is incorrect as increasing the dose of spironolactone would be inappropriate in the presence of elevated potassium levels.

3. What is a condition where the heart muscle becomes abnormally enlarged, thickened, or stiffened, often leading to heart failure?

• A. Cardiomyopathy
• B. Pericarditis
• C. Aortic stenosis
• D. Mitral valve prolapse

Correct answer: A

Rationale: Cardiomyopathy is the correct answer. It is a condition characterized by the abnormal enlargement, thickening, or stiffening of the heart muscle, which can lead to heart failure. Pericarditis (choice B) is inflammation of the pericardium, the sac surrounding the heart, not directly related to heart muscle enlargement. Aortic stenosis (choice C) is the narrowing of the aortic valve opening, affecting blood flow from the heart, but not directly related to heart muscle enlargement. Mitral valve prolapse (choice D) is a condition where the valve between the left atrium and left ventricle doesn't close properly, causing blood to leak backward, and is not directly related to heart muscle enlargement.

4. The client is on a nitrate for angina. What is the most common side effect the nurse should monitor for?

• A. Headache
• B. Flushing
• C. Dizziness
• D. Nausea

Correct answer: A

Rationale: The correct answer is A, Headache. Nitrates commonly cause headaches as a side effect due to vasodilation. Flushing, dizziness, and nausea are less common side effects associated with nitrates. Flushing is more related to the dilation of blood vessels closer to the skin's surface, dizziness could occur but is not as common as headaches, and nausea is a less typical side effect of nitrates.

5. Which heart chamber ejects blood into the systemic arterial circulation via the aorta?

• A. Right atrium
• B. Left atrium
• C. Right ventricle
• D. Left ventricle

Correct answer: D

Rationale: The correct answer is D, Left ventricle. The left ventricle pumps oxygenated blood into the systemic circulation via the aorta. This chamber receives oxygen-rich blood from the left atrium and contracts forcefully to propel blood into the aorta, distributing it to the body. The other options, right atrium, left atrium, and right ventricle, do not directly eject blood into the systemic arterial circulation via the aorta. The right atrium receives deoxygenated blood from the body, the left atrium receives oxygenated blood from the lungs, and the right ventricle pumps blood to the lungs for oxygenation.

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