Nursing Elites

1. The nurse is caring for a client on warfarin with an INR of 1.8. What is the most appropriate action?

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

Correct answer: D

Rationale: An INR of 1.8 is below the therapeutic range for a client on warfarin, indicating the need for monitoring closely to ensure that the INR levels reach the desired therapeutic range. Increasing the dose of warfarin (Choice A) without proper monitoring may lead to an increased risk of bleeding. Administering vitamin K (Choice B) is not typically recommended unless the client is experiencing major bleeding or requires rapid reversal of warfarin's effects. Holding the warfarin and notifying the healthcare provider (Choice C) may be necessary in certain situations, but the immediate action in this case should be to monitor the client's INR closely to guide further management.

2. A client on a beta blocker has a blood pressure of 90/60 mm Hg. What is the nurse’s priority action?

• A. Hold the beta blocker and notify the healthcare provider.
• B. Administer the beta blocker as ordered.
• C. Administer a diuretic to reduce blood pressure.
• D. Continue to monitor the client and reassess in 30 minutes.

Correct answer: A

Rationale: The correct answer is to hold the beta blocker and notify the healthcare provider. A blood pressure of 90/60 mm Hg is already low, and beta blockers can further decrease blood pressure. Administering the beta blocker can potentially worsen the situation, leading to complications. Administering a diuretic or continuing to monitor the client without taking immediate action could delay necessary intervention. Therefore, holding the beta blocker and involving the healthcare provider promptly is crucial in this scenario.

3. The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse’s priority action?

• A. Administer the beta blocker as ordered.
• B. Hold the beta blocker and notify the healthcare provider.
• C. Increase the dose of the beta blocker.
• D. Monitor the client’s heart rate and reassess in 30 minutes.

Correct answer: B

Rationale: The correct answer is B. A heart rate of 58 bpm is considered low, and beta blockers can further decrease the heart rate. Therefore, the nurse's priority action should be to hold the beta blocker and notify the healthcare provider for further assessment. Choice A is incorrect because administering the beta blocker without considering the low heart rate can worsen the condition. Choice C is incorrect as increasing the dose of the beta blocker can lead to further slowing of the heart rate, which is not safe in this situation. Choice D is not the priority action; holding the medication and seeking guidance from the healthcare provider is more crucial.

4. Which condition refers to the heart being unable to pump sufficient blood to meet the body's needs?

• A. Heart failure
• B. Myocardial infarction
• C. Cardiomyopathy
• D. Pericarditis

Correct answer: A

Rationale: The correct answer is A, heart failure. This condition occurs when the heart can't pump enough blood to fulfill the body's requirements. Myocardial infarction (choice B) is the medical term for a heart attack, which is caused by a blockage in the coronary arteries. Cardiomyopathy (choice C) is a disease of the heart muscle that makes it harder for the heart to pump blood. Pericarditis (choice D) is the inflammation of the pericardium, the thin sac-like membrane surrounding the heart, and does not specifically involve the heart's inability to pump sufficient blood.

5. What procedure is used to visualize the airways and diagnose lung disease?

• A. Bronchoscopy
• B. Thoracentesis
• C. Pulmonary function test
• D. Chest X-ray

Correct answer: A

Rationale: Bronchoscopy is the correct answer because it is a procedure specifically designed to visualize the airways and diagnose lung diseases by allowing doctors to examine the inside of the airways. Thoracentesis involves the removal of fluid from the pleural space around the lungs, not the airways. Pulmonary function tests assess how well the lungs work but do not visualize the airways directly. A chest X-ray provides an image of the lungs and surrounding structures but does not involve direct visualization of the airways.

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