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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What is the amount of tension the ventricle must develop during contraction to eject blood from the left ventricle into the aorta?
- A. Afterload
- B. Preload
- C. Automaticity
- D. Ejection fraction
Correct Answer: A
Rationale: The correct answer is A: Afterload. Afterload refers to the amount of tension the ventricle must develop during contraction to eject blood into the aorta. It is the resistance the heart must overcome to eject blood. Preload (B) is the stretch on the heart muscle before contraction. Automaticity (C) refers to the heart's ability to generate electrical impulses. Ejection fraction (D) is the percentage of blood pumped out of the ventricle with each heartbeat.
The nurse is caring for a client on enalapril (Vasotec). 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. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a common side effect. It is important to monitor for this because it can indicate a potentially serious adverse reaction called angioedema. Hyperkalemia (B) is a possible side effect of enalapril but is typically not as urgent to monitor as cough. Hypotension (C) is a common side effect but is usually monitored during the initial dose titration. Dizziness (D) is a less common side effect and is often transient. Monitoring for cough is crucial to detect and manage any potential angioedema promptly.
The nurse is caring for a client on heparin. What is the most important lab value to monitor?
- A. aPTT
- B. INR
- C. Platelet count
- D. Hemoglobin
Correct Answer: A
Rationale: The correct answer is A: aPTT. This lab value is crucial for monitoring heparin therapy as it measures the effectiveness of the medication in preventing blood clots. Monitoring aPTT helps ensure the client is within the therapeutic range to prevent bleeding or clotting complications. Incorrect choices:
B: INR is used to monitor warfarin therapy, not heparin.
C: Platelet count is important, but aPTT is more directly related to heparin therapy.
D: Hemoglobin is important for assessing anemia but not specific to monitoring heparin therapy.
When monitoring a client on dobutamine, what is the most important parameter to assess?
- A. Blood pressure
- B. Heart rate
- C. Oxygen saturation
- D. Respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Blood pressure. When monitoring a client on dobutamine, the most important parameter to assess is blood pressure because dobutamine is a medication that increases heart contractility, potentially leading to increased cardiac output and subsequent changes in blood pressure. Monitoring blood pressure helps to ensure that the medication is having the desired effect without causing adverse effects such as hypertension or hypotension. Heart rate (B) can be influenced by dobutamine but is not as critical as blood pressure. Oxygen saturation (C) and respiratory rate (D) are important parameters to monitor in general but are not directly influenced by dobutamine.
The client on amiodarone reports shortness of breath. What is the nurse's best response?
- A. Notify the healthcare provider immediately.
- B. Reassure the client that this is a common side effect.
- C. Instruct the client to monitor their symptoms at home.
- D. Suggest the client reduce physical activity.
Correct Answer: A
Rationale: The correct answer is A: Notify the healthcare provider immediately. Shortness of breath in a client on amiodarone can indicate a serious side effect such as pulmonary toxicity or interstitial lung disease. The nurse should prioritize the client's safety by promptly informing the healthcare provider for further evaluation and management. This is crucial to prevent potential harm or worsening of the condition.
Summary:
- Choice B is incorrect because shortness of breath with amiodarone is not a common side effect to be reassured about.
- Choice C is incorrect as monitoring symptoms at home may delay necessary medical intervention.
- Choice D is incorrect as reducing physical activity does not address the potential serious side effect of amiodarone.