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 client on atorvastatin (Lipitor) should be advised to report which of the following symptoms?

• A. Muscle pain
• B. Headache
• C. Nausea
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A: Muscle pain. Muscle pain can be a sign of rhabdomyolysis, a serious side effect of statins like atorvastatin. Rhabdomyolysis is a condition where muscle fibers break down rapidly and release their contents into the bloodstream, which can lead to kidney damage. Headache, nausea, and dizziness are not commonly associated with atorvastatin use and are less likely to indicate a serious adverse reaction compared to muscle pain.

3. The client on clopidogrel (Plavix) should be monitored for which adverse effect?

• A. Bleeding
• B. Hypertension
• C. Tachycardia
• D. Bradycardia

Correct answer: A

Rationale: Correct! Clopidogrel (Plavix) is an antiplatelet medication that helps prevent blood clots. As a side effect, it can increase the risk of bleeding. Monitoring for signs of bleeding, such as easy bruising, blood in urine or stools, or prolonged bleeding from cuts, is crucial. Choices B, C, and D are incorrect as hypertension, tachycardia, and bradycardia are not typically associated with clopidogrel use.

4. Which of the following is a chronic respiratory disease characterized by the irreversible obstruction of airflow?

• A. Chronic obstructive pulmonary disease (COPD)
• B. Asthma
• C. Pulmonary edema
• D. Bronchiectasis

Correct answer: A

Rationale: The correct answer is A, Chronic obstructive pulmonary disease (COPD). COPD is a chronic respiratory disease where the airflow in the lungs becomes obstructed, making it difficult to breathe. Choice B, Asthma, is a different chronic respiratory condition characterized by reversible airflow obstruction and airway hyperresponsiveness. Choice C, Pulmonary edema, is a condition where fluid accumulates in the lungs, leading to difficulty in breathing but not irreversible airflow obstruction. Choice D, Bronchiectasis, is a condition characterized by abnormal widening of the bronchial tubes, leading to recurrent respiratory infections, but it is not specifically defined by irreversible airflow obstruction.

5. This is a type of therapy that involves removing fluid from the lungs, typically through the use of diuretics.

• A. Diuretic therapy
• B. Oxygen therapy
• C. Inhaler therapy
• D. Antihistamine therapy

Correct answer: A

Rationale: The correct answer is A: Diuretic therapy. Diuretic therapy involves the use of medications that help remove excess fluid from the body, often used to treat conditions like pulmonary edema. Choice B, Oxygen therapy, is used to provide oxygen to patients with breathing difficulties but does not involve removing fluid from the lungs. Choice C, Inhaler therapy, is used to deliver medication directly to the lungs to help with respiratory conditions but does not focus on removing fluid. Choice D, Antihistamine therapy, is used to treat allergies by blocking histamine but is not related to removing fluid from the lungs.

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