Nokea
The client is on warfarin and has an INR of 1.5. What is the nurse's priority action?
- A. Increase the dose of warfarin.
- B. Hold the next dose of warfarin.
- C. Continue the current dose of warfarin.
- D. Monitor the client's INR closely.
Correct Answer: B
Rationale: The correct answer is B: Hold the next dose of warfarin. With an INR of 1.5, the client's blood is not adequately anticoagulated, increasing the risk of blood clots. Holding the next dose will prevent further thinning of blood and allow the INR to increase to the target range. Increasing the dose (A) could lead to over-anticoagulation, risking bleeding. Continuing the current dose (C) maintains inadequate anticoagulation. Monitoring (D) is important, but the immediate action should be to hold the next dose.
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What is the term used to describe a condition where the blood flow to the brain is temporarily interrupted, often referred to as a 'mini-stroke'?
- A. Transient ischemic attack (TIA)
- B. Stroke
- C. Myocardial infarction
- D. Pulmonary embolism
Correct Answer: A
Rationale: The correct answer is A: Transient ischemic attack (TIA). A TIA is a temporary interruption of blood flow to the brain, causing stroke-like symptoms that usually resolve within 24 hours. It is often referred to as a 'mini-stroke' because the symptoms are similar to a stroke but last for a shorter duration.
Explanation:
1. TIA specifically describes a temporary interruption of blood flow to the brain, aligning with the scenario described in the question.
2. Stroke (Choice B) refers to a more severe and lasting interruption of blood flow to the brain, not a temporary one as seen in a TIA.
3. Myocardial infarction (Choice C) refers to a heart attack, which involves blockage of blood flow to the heart muscle, not the brain.
4. Pulmonary embolism (Choice D) is a blockage of an artery in the lungs, not related to blood flow interruption to the brain.
In summary,
A patient who underwent a percutaneous, transluminal coronary angioplasty four weeks ago has a subsequent ejection fraction of 30%. The patient returns for a follow-up visit. Examination reveals lungs that are clear on auscultation and slight pedal edema. The patient's medications are digoxin (Lanoxin), furosemide (Lasix), enalapril maleate (Vasotec), and aspirin. The patient reports a 5 lb (2.27 kg) weight gain over the past two days. The cardiac-vascular nurse's initial action is to:
- A. document the weight and reassess the patient at the next session.
- B. inquire about the patient's medication compliance.
- C. notify the patient's physician.
- D. review the patient's most recent nuclear scan.
Correct Answer: B
Rationale: Weight gain and pedal edema suggest fluid retention, so assessing medication compliance is essential.
What is the term that describes the inability of cardiac cells to respond to a new stimulus while they are still in contraction from a previous stimulus?
- A. Refractoriness
- B. Excitability
- C. Contractility
- D. Automaticity
Correct Answer: A
Rationale: The correct answer is A: Refractoriness. Refractoriness refers to the period during which cardiac cells are unable to respond to a new stimulus while still contracting from a previous stimulus. This is essential for preventing premature re-stimulation and ensuring proper cardiac function.
B: Excitability refers to the ability of cardiac cells to respond to a stimulus, which is the opposite of what is described in the question.
C: Contractility is the ability of cardiac cells to contract in response to an electrical stimulus, not related to the inability to respond to a new stimulus during contraction.
D: Automaticity is the ability of cardiac cells to spontaneously generate electrical impulses, unrelated to the inability to respond to a new stimulus during contraction.
The nurse is teaching a client about side effects of ACE inhibitors. What is the most important side effect to monitor?
- A. Cough
- B. Hyperkalemia
- C. Hypotension
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Cough. ACE inhibitors can cause a persistent, dry cough due to bradykinin accumulation. It is important to monitor for this as it can indicate potential angioedema, a serious adverse effect. Hyperkalemia (B) is a potential side effect but may not be as immediate or common as cough. Hypotension (C) is a common side effect but not as crucial to monitor as cough. Dizziness (D) is a common side effect but not as significant as cough in terms of potential complications.
What is a condition where blood clots form in the deep veins, usually in the legs, and can travel to the lungs, causing serious complications?
- A. Deep vein thrombosis (DVT)
- B. Pulmonary embolism
- C. Varicose veins
- D. Peripheral artery disease
Correct Answer: A
Rationale: The correct answer is A: Deep vein thrombosis (DVT). DVT is a condition where blood clots form in the deep veins, typically in the legs. These clots can dislodge and travel to the lungs, leading to a pulmonary embolism. Choice B, pulmonary embolism, is a complication of DVT, not the initial condition. Varicose veins (C) are enlarged, twisted veins usually visible on the skin surface, not deep veins. Peripheral artery disease (D) involves narrowed arteries, not blood clots in veins.