Nokea
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: The correct answer is A: Administer vitamin K as an antidote. An INR of 5.5 indicates the client is at risk for bleeding due to excessive anticoagulation from warfarin. Administering vitamin K helps reverse the effects of warfarin and lowers the INR back to the therapeutic range. Holding the next dose of warfarin (B) is important but not the priority over administering the antidote. Increasing the dose of warfarin (C) would worsen the situation. Administering fresh frozen plasma (D) is not a standard treatment for high INR levels due to warfarin.
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Which heart chamber receives oxygenated blood from the four pulmonary veins and serves as a reservoir during ventricular systole?
- A. Right atrium
- B. Left atrium
- C. Right ventricle
- D. Left ventricle
Correct Answer: B
Rationale: The correct answer is B: Left atrium. The left atrium receives oxygenated blood from the pulmonary veins, acting as a reservoir during ventricular systole. This blood is then pumped into the left ventricle for distribution to the body. The right atrium receives deoxygenated blood from the body via the vena cavae. The right ventricle pumps this blood to the lungs for oxygenation. The left ventricle is responsible for pumping oxygenated blood to the rest of the body. Therefore, the left atrium is the correct choice based on its role in receiving oxygenated blood from the pulmonary veins.
The nurse is administering enoxaparin (Lovenox) to a client. What is the most important lab value to monitor?
- A. Platelet count
- B. Hemoglobin
- C. White blood cell count
- D. aPTT
Correct Answer: A
Rationale: The correct answer is A: Platelet count. Enoxaparin is an anticoagulant that works by preventing blood clots. Monitoring platelet count is crucial to assess for potential thrombocytopenia, a side effect of enoxaparin that can increase the risk of bleeding. Hemoglobin (B) and White blood cell count (C) are not directly affected by enoxaparin. aPTT (D) is not the most important lab value to monitor as enoxaparin does not directly affect this clotting parameter.
The client is on dobutamine. Adverse effects of Dobutrex (dobutamine) include the following: Select all that apply.
- A. Heart failure
- B. Bradycardia
- C. Tachycardia
- D. Respiratory distress
Correct Answer: C
Rationale: Step-by-step rationale:
1. Dobutamine is a beta-1 adrenergic agonist, which increases heart rate.
2. Tachycardia is a common adverse effect due to increased heart rate.
3. Bradycardia is the opposite effect and not expected with dobutamine.
4. Heart failure is a condition that dobutamine is used to treat, not cause.
5. Respiratory distress is not a typical adverse effect of dobutamine.
Summary:
Choice C (Tachycardia) is correct because dobutamine increases heart rate. Choices A, B, and D are incorrect because dobutamine does not cause heart failure, bradycardia, or respiratory distress.
To detect and treat the most common complication of MI, what should the nurse do?
- A. Measure hourly urine output
- B. Auscultate the chest for crackles
- C. Use continuous cardiac monitoring
- D. Take vital signs every 2 hours for the first 8 hours
Correct Answer: C
Rationale: Continuous monitoring detects dysrhythmias.
The nurse determines that the treatment of heart failure has been successful when the patient experiences
- A. Weight loss and diuresis
- B. Warm skin and less fatigue
- C. Clear lung sounds and decreased heart rate
- D. Absence of chest pain and improved LOC
Correct Answer: C
Rationale: Successful treatment of heart failure is indicated by an absence of symptoms of pulmonary edema and hypoxemia, such as clear lung sounds and a normal heart rate.