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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The client asks about side effects of taking digoxin. How does the nurse respond?
- A. Anorexia can be a side effect of digoxin.
- B. Tachycardia can be a side effect of digoxin.
- C. Constipation can be a side effect of digoxin.
- D. Urinary retention can be a side effect of digoxin.
Correct Answer: A
Rationale: The correct answer is A: Anorexia can be a side effect of digoxin. Digoxin is known to cause anorexia due to its impact on the gastrointestinal system. It can lead to nausea, vomiting, and loss of appetite, resulting in anorexia. Tachycardia (choice B) is not a common side effect of digoxin, as it is actually used to treat certain types of arrhythmias. Constipation (choice C) and urinary retention (choice D) are also not typically associated with digoxin use. In summary, anorexia is a known side effect of digoxin, while tachycardia, constipation, and urinary retention are not commonly linked to this medication.
Which condition involves the tearing of the aorta, leading to severe pain and internal bleeding?
- A. Aortic dissection
- B. Aneurysm
- C. Stroke
- D. Myocardial infarction
Correct Answer: A
Rationale: The correct answer is A: Aortic dissection. This condition involves a tear in the inner layer of the aorta, leading to severe pain and internal bleeding. The tearing causes blood to flow between the layers of the aortic wall, which can be life-threatening. Aneurysm (B) is the abnormal bulging of a weakened blood vessel, not necessarily involving tearing. Stroke (C) is a brain-related condition, not related to the aorta. Myocardial infarction (D) is a heart attack due to blockage of blood flow to the heart, not directly involving the aorta.
Discuss the strategies to prevent ventilator-associated pneumonia.
- A. Oral hygiene
- B. Elevation of head
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: Prevention includes maintaining oral hygiene and elevating the head of the bed.
What is the amount of blood the heart pumps through the circulatory system in a minute?
- A. Cardiac output
- B. Stroke volume
- C. End-diastolic volume
- D. Ejection fraction
Correct Answer: A
Rationale: The correct answer is A: Cardiac output. Cardiac output is the total amount of blood pumped by the heart in a minute. It is calculated by multiplying the heart rate (beats per minute) by the stroke volume (amount of blood pumped per beat). This measurement gives an indication of how effectively the heart is functioning in delivering oxygenated blood to the body.
B: Stroke volume is the amount of blood pumped by the heart in each beat, not the total amount in a minute.
C: End-diastolic volume is the amount of blood in the ventricles before contraction, not the total amount pumped in a minute.
D: Ejection fraction is the percentage of blood pumped out of the ventricles with each contraction, not the total amount in a minute.
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.