Nokea
The client on warfarin has an INR of 3.8. What is the most appropriate action by the nurse?
- A. Administer vitamin K.
- B. Hold the next dose of warfarin.
- C. Increase the dose of warfarin.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR above the therapeutic range (usually 2-3), like in this case (3.8), administering vitamin K is appropriate to reverse the anticoagulant effects. This helps prevent bleeding complications. Holding the next dose of warfarin (B) may not be sufficient to lower the INR quickly. Increasing the dose of warfarin (C) would further elevate the INR, leading to higher bleeding risk. Notifying the healthcare provider (D) is important, but immediate action with vitamin K is necessary to address the high INR.
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Which condition is characterized by the lungs becoming scarred and stiff, leading to difficulty breathing and inadequate oxygen intake into the bloodstream?
- A. Pulmonary fibrosis
- B. Cystic fibrosis
- C. COPD
- D. Tuberculosis
Correct Answer: A
Rationale: Pulmonary fibrosis is characterized by scarring and stiffening of the lungs, impairing their ability to expand and contract properly for breathing. This leads to difficulty breathing and inadequate oxygen intake into the bloodstream. In contrast, cystic fibrosis primarily affects the respiratory and digestive systems, COPD is a progressive lung disease primarily caused by smoking, and tuberculosis is a bacterial infection that primarily affects the lungs. Therefore, the correct answer is A because it specifically describes the scarring and stiffness of the lungs resulting in breathing difficulties and inadequate oxygen intake.
In third-degree atrioventricular block, all sinus impulses fail to activate the ventricles. This will be detected by
- A. A highly variable PR interval
- B. Regular PP intervals
- C. A slow heart rate
- D. Regular RR intervals
Correct Answer: C
Rationale: Slow heart rate reflects lack of conduction from atria to ventricles.
For what reason might the nurse be given an order to administer milrinone (Primacor)?
- A. For congestive heart failure
- B. For hypertension
- C. For cardiac arrhythmias
- D. For bradycardia
Correct Answer: A
Rationale: The correct answer is A: For congestive heart failure. Milrinone is a phosphodiesterase inhibitor used to improve cardiac output in patients with severe heart failure. It works by increasing the force of heart contractions. Therefore, it is specifically indicated for congestive heart failure to help improve cardiac function. Choices B, C, and D are incorrect because milrinone is not typically used for hypertension, cardiac arrhythmias, or bradycardia. It is important to understand the specific indications and mechanisms of action of medications to determine the appropriate use in clinical practice.
Which term refers to a condition where the blood supply to part of the heart muscle is blocked, often referred to as a heart attack?
- A. Myocardial infarction
- B. Arrhythmia
- C. Stroke
- D. Aneurysm
Correct Answer: A
Rationale: The correct answer is A: Myocardial infarction. Myocardial infarction refers to the condition where the blood supply to part of the heart muscle is blocked, leading to tissue damage or cell death. This is commonly known as a heart attack. It is crucial to understand that arrhythmia (B), stroke (C), and aneurysm (D) are different medical conditions that do not specifically involve the blockage of blood flow to the heart muscle. Arrhythmia is an irregular heartbeat, stroke is the interruption of blood supply to the brain, and an aneurysm is a bulge in a blood vessel. Therefore, the correct term for a condition involving a blocked blood supply to the heart muscle is myocardial infarction.
The client is receiving intravenous dopamine. What is the most important nursing assessment?
- A. Monitor heart rate and rhythm
- B. Monitor blood pressure
- C. Monitor respiratory rate
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is A: Monitor heart rate and rhythm. Dopamine is a medication that can affect the heart rate and rhythm. Monitoring these parameters is crucial to detect any potential adverse effects such as tachycardia or arrhythmias. Monitoring blood pressure is also important, but assessing heart rate and rhythm takes precedence due to the direct impact of dopamine on cardiac function. Respiratory rate and oxygen saturation are generally not directly affected by dopamine administration.