Nursing Elites

1. The client on warfarin has an INR of 4.5. What is the most appropriate action by the nurse?

• A. Administer vitamin K.
• B. Hold the next dose of warfarin.
• C. Increase the dose of warfarin.
• D. Monitor the client’s INR closely.

Correct answer: A

Rationale: An INR of 4.5 is elevated, indicating an increased risk of bleeding due to excessive anticoagulation. The most appropriate action for the nurse in this scenario is to administer vitamin K. Vitamin K helps reverse the anticoagulant effects of warfarin, thus lowering the INR and reducing the risk of bleeding. Holding the next dose of warfarin (choice B) is not sufficient to address the immediate high INR level. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the risk of bleeding. While monitoring the client's INR closely (choice D) is important, immediate action is required to address the critically high INR level, making the administration of vitamin K the priority intervention.

2. The nurse is caring for a client on digoxin. What is the most important assessment before administering this medication?

• A. Check the client’s heart rate.
• B. Check the client’s blood pressure.
• C. Check the client’s respiratory rate.
• D. Check the client’s oxygen saturation.

Correct answer: A

Rationale: The correct answer is to check the client’s heart rate before administering digoxin because one of the side effects of digoxin is bradycardia. Monitoring the heart rate is crucial to assess whether the client's heart rate is within the acceptable range before giving the medication. Checking the blood pressure (Choice B), respiratory rate (Choice C), or oxygen saturation (Choice D) are important assessments in general patient care, but they are not specifically related to the administration of digoxin.

3. What condition involves a weakened and bulging aorta, the main artery in the body, potentially leading to rupture?

• A. Aortic aneurysm
• B. Arterial stenosis
• C. Pulmonary embolism
• D. Deep vein thrombosis

Correct answer: A

Rationale: An aortic aneurysm is a condition characterized by the weakening and bulging of the aorta, the body's main artery. If left untreated, this bulging may lead to a rupture, causing severe complications. Arterial stenosis refers to the narrowing of an artery, not the weakening and bulging seen in an aortic aneurysm. Pulmonary embolism involves a blockage in the pulmonary artery, which is different from the weakening and bulging in an aortic aneurysm. Deep vein thrombosis is the formation of a blood clot in a deep vein, not related to the condition described in the question.

4. Which of the following is a type of heart attack that occurs when the blood supply to part of the heart muscle is severely reduced or stopped?

• A. Myocardial infarction
• B. Angina
• C. Stroke
• D. Congestive heart failure

Correct answer: A

Rationale: The correct answer is A: Myocardial infarction. Myocardial infarction, commonly known as a heart attack, occurs when the blood supply to part of the heart muscle is severely reduced or stopped, leading to tissue damage or death. Angina (choice B) is chest pain or discomfort that occurs when the heart muscle doesn't get enough oxygen-rich blood. Stroke (choice C) is a condition where the blood supply to the brain is interrupted or reduced. Congestive heart failure (choice D) is a chronic condition where the heart muscle doesn't pump blood as well as it should.

5. The nurse is administering an ACE inhibitor to a client. What is the most common side effect?

• A. Cough
• B. Dizziness
• C. Hypotension
• D. Hyperkalemia

Correct answer: A

Rationale: The correct answer is A: Cough. Cough is a well-known side effect of ACE inhibitors due to an increase in bradykinin levels. This irritating cough can be bothersome to clients and should be monitored. Choice B, Dizziness, is not the most common side effect of ACE inhibitors. While ACE inhibitors can cause hypotension (Choice C), cough is more prevalent. Hyperkalemia (Choice D) is a possible side effect of ACE inhibitors but is less common compared to cough.

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