Nokea
The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
- A. Monitor the client's heart rate.
- B. Check the client's blood pressure.
- C. Check for signs of bleeding.
- D. Monitor the client's respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's heart rate. When administering an IV bolus of heparin, it is crucial to monitor the client's heart rate because heparin can cause serious side effects such as bleeding and heparin-induced thrombocytopenia, which can lead to changes in heart rate. Checking blood pressure (B) is also important but not as critical as monitoring heart rate. Checking for signs of bleeding (C) is necessary but should be done after monitoring the heart rate. Monitoring the client's respiratory rate (D) is not directly related to heparin administration.
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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.
What is a condition where the airways become inflamed and narrow, making breathing difficult?
- A. Asthma
- B. Bronchitis
- C. Pleurisy
- D. Tuberculosis
Correct Answer: A
Rationale: Asthma is the correct answer because it is a condition characterized by inflammation and narrowing of the airways, leading to difficulty in breathing. This is due to various triggers causing the airways to become inflamed, swollen, and produce excess mucus, resulting in constriction and breathing difficulties. Bronchitis, Pleurisy, and Tuberculosis do not directly involve narrowing of the airways as their primary mechanism, making them incorrect choices. Bronchitis is inflammation of the bronchial tubes, Pleurisy is inflammation of the lining around the lungs, and Tuberculosis is a bacterial infection primarily affecting the lungs.
What is the condition where the lung collapses due to air leaking into the space between the lung and chest wall?
- A. Pneumothorax
- B. Pleural effusion
- C. Pulmonary fibrosis
- D. Lung cancer
Correct Answer: A
Rationale: The correct answer is A: Pneumothorax. This condition occurs when air enters the pleural space, causing the lung to collapse. The air disrupts the pressure balance, leading to lung collapse. Pleural effusion (B) is the accumulation of fluid in the pleural space, not air. Pulmonary fibrosis (C) is scarring of lung tissue, unrelated to air leakage. Lung cancer (D) is the abnormal growth of cells in the lung, not directly causing air leakage.
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 test measures the electrical activity of the heart and can detect arrhythmias and other heart conditions?
- A. Electrocardiogram (ECG or EKG)
- B. Chest X-ray
- C. MRI
- D. CT scan
Correct Answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG or EKG). An ECG measures the electrical activity of the heart, detecting arrhythmias and other heart conditions by recording the heart's electrical impulses. This test is non-invasive and provides valuable information about the heart's function. Chest X-ray (B) primarily shows the heart's size and shape, not electrical activity. MRI (C) and CT scan (D) are imaging tests that provide detailed anatomical images but do not directly measure heart electrical activity.