Nokea
The client on warfarin has an INR of 4.5. 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. Monitor the client's INR closely.
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR of 4.5, it indicates over-anticoagulation, putting them at risk of bleeding. Vitamin K helps reverse the effects of warfarin by promoting clotting factors. Administering vitamin K will lower the INR back into the therapeutic range. Holding the next dose of warfarin (B) is not enough to rapidly reverse the effects. Increasing the dose of warfarin (C) would worsen the over-anticoagulation. Monitoring the INR closely (D) is important but not the immediate action needed for a high INR.
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The healthcare provider is monitoring a client on an ACE inhibitor. What lab value is most important to monitor?
- A. Potassium
- B. Sodium
- C. Creatinine
- D. Calcium
Correct Answer: A
Rationale: The correct answer is A: Potassium. ACE inhibitors can cause hyperkalemia, so monitoring potassium levels is crucial to prevent potential life-threatening complications. High potassium levels can lead to cardiac arrhythmias. Sodium levels are not typically affected by ACE inhibitors. Creatinine is important to monitor for kidney function but not specific to ACE inhibitors. Calcium levels are not directly affected by ACE inhibitors.
What is a condition where the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients?
- A. Stroke
- B. Heart attack
- C. Pulmonary embolism
- D. Pneumonia
Correct Answer: A
Rationale: The correct answer is A: Stroke. A stroke occurs when the blood supply to part of the brain is interrupted or reduced, leading to brain tissue not receiving enough oxygen and nutrients. This can result in permanent brain damage or even death.
Choice B: Heart attack, involves a blockage in the blood vessels supplying the heart muscle, not the brain.
Choice C: Pulmonary embolism, is a blockage in the arteries of the lungs, not the brain.
Choice D: Pneumonia, is an infection in the lungs and does not directly involve the brain's blood supply.
In summary, a stroke specifically affects the brain's blood supply and can lead to serious consequences, unlike the other conditions mentioned.
The nurse is caring for a client on amiodarone. What adverse effect is the nurse most concerned about?
- A. Pulmonary toxicity
- B. Liver toxicity
- C. Thyroid dysfunction
- D. Renal dysfunction
Correct Answer: A
Rationale: The correct answer is A: Pulmonary toxicity. Amiodarone is known to cause potentially life-threatening pulmonary toxicity, including interstitial pneumonitis and pulmonary fibrosis. The nurse must closely monitor the client for signs such as cough, dyspnea, and chest pain. Liver toxicity (B), thyroid dysfunction (C), and renal dysfunction (D) are also possible adverse effects of amiodarone, but pulmonary toxicity is the most concerning due to its severe and rapid progression. Monitoring and early detection are crucial to prevent serious complications.
Define ventilation and respiration.
- A. Gas exchange
- B. Breathing process
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: Ventilation refers to breathing, while respiration involves gas exchange at cellular level.
A client with dysrhythmia has decreased cardiac output. Which of the following nursing interventions is essential to maintain adequate cardiac output?
- A. Encourage mild exercises
- B. Place the client in supine position
- C. Ensure a client IV access
- D. Provide supplemental oxygen
Correct Answer: D
Rationale: Supplemental oxygen improves oxygen delivery to tissues, supporting cardiac output in clients with dysrhythmias.