Nokea
The nurse is caring for a client on warfarin with an INR of 5.2. What is the most appropriate action?
- A. Administer vitamin K as an antidote.
- 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 as an antidote. A high INR level of 5.2 indicates the client is at risk of bleeding due to excess anticoagulation from warfarin. Vitamin K helps reverse the effects of warfarin by promoting clotting factor production. Administering vitamin K is crucial to prevent bleeding complications. Holding the next dose of warfarin (B) is not enough to rapidly lower the INR. Increasing the dose of warfarin (C) would worsen the situation. Monitoring the client's INR closely (D) is important, but immediate action with vitamin K is necessary in this case.
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The nurse is administering digoxin to a client with a heart rate of 45 bpm. What is the nurse's priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Administer the digoxin as ordered.
- C. Increase the dose of digoxin.
- D. Monitor the client's heart rate and reassess in 30 minutes.
Correct Answer: A
Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. Digoxin is a medication that can slow down the heart rate, and a heart rate of 45 bpm is below the normal range. Holding the medication and informing the healthcare provider is the priority to prevent potential harm from further slowing the heart rate. Administering the digoxin as ordered (B) would worsen the bradycardia. Increasing the dose of digoxin (C) would be dangerous. Monitoring the client's heart rate and reassessing in 30 minutes (D) may delay necessary intervention.
What are the pressure-sensitive structures located in the aortic and carotid bodies called?
- A. Baroreceptors
- B. Chemoreceptors
- C. Nociceptors
- D. Mechanoreceptors
Correct Answer: A
Rationale: The correct answer is A: Baroreceptors. Baroreceptors are pressure-sensitive structures that detect changes in blood pressure in the aortic and carotid bodies. They help regulate blood pressure by sending signals to the brain to adjust heart rate and blood vessel dilation. Chemoreceptors (B) detect changes in chemical composition, not pressure. Nociceptors (C) detect pain stimuli. Mechanoreceptors (D) detect mechanical stimuli, not specifically pressure changes. Therefore, the correct answer is A as baroreceptors specifically respond to changes in blood pressure.
The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is elevated (normal range is 3.5-5.0 mEq/L). Spironolactone is a potassium-sparing diuretic, so the priority action is to hold the medication to prevent further elevation of potassium levels, which can lead to serious cardiac arrhythmias. Notifying the healthcare provider is crucial for further management. Administering potassium supplements (B) would further increase potassium levels. Continuing spironolactone as ordered (C) would exacerbate hyperkalemia. Increasing the dose of spironolactone (D) would be contraindicated in this situation.
Which valve prevents backflow of blood into the right ventricle from the pulmonary artery?
- A. Pulmonary valve
- B. Aortic valve
- C. Tricuspid valve
- D. Mitral valve
Correct Answer: A
Rationale: The correct answer is A: Pulmonary valve. This valve prevents backflow of blood into the right ventricle from the pulmonary artery by closing when the right ventricle relaxes. The pulmonary valve ensures that blood flows in one direction, from the right ventricle to the pulmonary artery. The other choices, B: Aortic valve, C: Tricuspid valve, and D: Mitral valve, are incorrect because they are not located between the right ventricle and the pulmonary artery. The aortic valve is between the left ventricle and the aorta, the tricuspid valve is between the right atrium and ventricle, and the mitral valve is between the left atrium and ventricle.
What is the condition where a blood clot blocks an artery in the lungs, causing shortness of breath, chest pain, and other symptoms?
- A. Pulmonary embolism
- B. Pneumothorax
- C. Pleural effusion
- D. Aneurysm
Correct Answer: A
Rationale: The correct answer is A: Pulmonary embolism. A pulmonary embolism occurs when a blood clot travels to the lungs and blocks an artery, leading to symptoms like shortness of breath and chest pain. This happens because the clot obstructs blood flow to the lung tissue, causing a decrease in oxygen levels. The other choices, B: Pneumothorax, C: Pleural effusion, and D: Aneurysm, do not involve a blood clot blocking an artery in the lungs. Pneumothorax is a collapsed lung due to air in the chest cavity, Pleural effusion is the accumulation of fluid in the space between the lungs and chest wall, and an Aneurysm is a bulging and weakened blood vessel.