the nurse is caring for a client on warfarin with an inr of 52 what is the most appropriate action
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Nursing Elites

ATI RN

Physical Exam Cardiovascular System

1. The nurse is caring for a client on warfarin with an INR of 5.2. What is the most appropriate action?

Correct answer: A

Rationale: An INR of 5.2 is elevated, indicating an increased risk of bleeding. Administering vitamin K can help reverse the effects of warfarin, which is the most appropriate action in this situation. Holding the next dose of warfarin is not enough to address the high INR, and increasing the dose would further elevate the INR level. Monitoring the INR closely is important, but in this case, immediate action is needed to counteract the anticoagulant effects of warfarin.

2. What is a condition where the heart's valves do not function properly, leading to disrupted blood flow within the heart?

Correct answer: A

Rationale: Valvular heart disease is the correct answer. It occurs when the heart's valves malfunction, leading to disrupted blood flow within the heart. Myocarditis refers to inflammation of the heart muscle, not specifically related to valve function. Endocarditis is an infection of the inner lining of the heart chambers and valves, not necessarily caused by valve malfunction. Aneurysm is the abnormal bulging of a blood vessel, not directly related to heart valve function.

3. What is the ability of cardiac cells to respond to an impulse by transmitting the impulse along cell membranes?

Correct answer: C

Rationale: The correct answer is C, Conductivity. Conductivity refers to the ability of cardiac cells to transmit impulses along cell membranes. Contractility (Choice A) is the ability of cardiac cells to contract in response to an electrical stimulus, not transmit impulses. Automaticity (Choice B) is the ability of cardiac cells to spontaneously generate electrical impulses. Rhythmicity (Choice D) refers to the regular generation of electrical impulses by the heart's pacemaker cells, not the transmission of impulses along cell membranes.

4. What is the condition where the heart's mitral valve becomes narrowed, restricting blood flow from the left atrium to the left ventricle?

Correct answer: A

Rationale: Mitral stenosis is the correct answer. It is a condition characterized by the narrowing of the heart's mitral valve, which hinders the flow of blood from the left atrium to the left ventricle. This obstruction can lead to symptoms such as shortness of breath and fatigue. Aortic stenosis (choice B) is the narrowing of the aortic valve, not the mitral valve. Tricuspid regurgitation (choice C) is the backflow of blood through the tricuspid valve, not narrowing. Pulmonary hypertension (choice D) is increased blood pressure in the pulmonary arteries, not narrowing of the mitral valve.

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

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.

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