Nursing Elites

1. The client on warfarin has an INR of 5.5. What is the priority nursing action?

• A. Administer vitamin K as an antidote.
• B. Hold the next dose of warfarin.
• C. Increase the dose of warfarin.
• D. Administer fresh frozen plasma.

Correct answer: A

Rationale: An INR of 5.5 is significantly elevated, indicating an increased risk of bleeding. The priority nursing action in this situation is to administer vitamin K as an antidote to reverse the effects of warfarin and lower the INR. Holding the next dose of warfarin (choice B) is important but not as immediate as administering vitamin K. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the bleeding risk. Administering fresh frozen plasma (choice D) is not the first-line treatment for high INR due to warfarin.

2. The client is on amiodarone and reports blurred vision. What is the nurse’s best response?

• A. Reassure the client that this is a common side effect.
• B. Instruct the client to report this symptom to the healthcare provider immediately.
• C. Advise the client to stop taking the medication.
• D. Discontinue the amiodarone immediately.

Correct answer: B

Rationale: Blurred vision is a potential side effect of amiodarone. Instructing the client to report this symptom to the healthcare provider immediately is the most appropriate response. Choice A is incorrect because although blurred vision can be a common side effect of amiodarone, it should not be dismissed without further evaluation. Choice C is incorrect as advising the client to stop taking the medication without consulting the healthcare provider can be dangerous and is not the first course of action. Choice D is too drastic as discontinuing the medication should be done under the guidance of a healthcare provider after proper evaluation.

3. What is the primary effect of a calcium channel blocker on the heart?

• A. Decreases heart rate
• B. Increases heart rate
• C. Increases blood pressure
• D. Decreases blood pressure

Correct answer: D

Rationale: The correct answer is D: Decreases blood pressure. Calcium channel blockers primarily work by relaxing blood vessels, leading to a decrease in blood pressure. While these medications can have secondary effects on the heart, such as reducing the workload of the heart muscle, the primary effect related to blood pressure regulation. Therefore, choices A, B, and C are incorrect as they do not reflect the primary action of calcium channel blockers on the heart.

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. The nurse is giving nitroglycerin sublingually for chest pain. What is the most important instruction to give to the client?

• A. Place the tablet under the tongue and let it dissolve completely.
• B. Swallow the tablet whole with a glass of water.
• C. Chew the tablet and then swallow it.
• D. Take one tablet every 5 minutes until pain is relieved.

Correct answer: A

Rationale: The correct answer is A. The tablet should be placed under the tongue and allowed to dissolve completely to ensure rapid absorption. This route of administration allows the medication to be quickly absorbed into the bloodstream. Choice B is incorrect because nitroglycerin is meant to be absorbed sublingually, not swallowed. Choice C is incorrect as chewing the tablet can cause the medication to be rapidly absorbed, leading to adverse effects like a drop in blood pressure. Choice D is incorrect because the client should take only one tablet every 5 minutes up to a maximum of three tablets for chest pain relief.

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