Nokea
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?
- A. Administer the medication as ordered.
- B. Prepare to administer vitamin K (AquaMephyton).
- C. Hold the medication and notify the HCP.
- D. Assess the client for abnormal bleeding.
Correct Answer: A
Rationale: INR 2.7 (A) is within the therapeutic range (2–3) for mechanical valves, so administer warfarin. Vitamin K (B) reverses anticoagulation, holding (C) is unnecessary, and bleeding (D) is routine but not primary.
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The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?
- A. Notify the health-care provider immediately.
- B. Elevate the head of the client's bed.
- C. Document this as a normal and expected finding.
- D. Administer morphine intravenously.
Correct Answer: A
Rationale: An S3 heart sound post-MI (A) indicates heart failure, requiring HCP notification. Elevating HOB (B) is supportive, documenting as normal (C) is incorrect, and morphine (D) is for pain.
The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?
- A. Wait until the machine discharges.
- B. Shout 'all clear' and don’t touch the bed.
- C. Make sure the client is all right.
- D. Increase the joules and redischarge.
Correct Answer: A
Rationale: A pause in synchronized cardioversion is normal as the machine syncs with the QRS complex; wait for discharge (A). 'All clear' (B) is for defibrillation, checking client (C) is premature, and increasing joules (D) is incorrect.
The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first?
- A. Do you have the money to buy your medication?'
- B. Does the medication give unwanted side effects?'
- C. Did you quit taking the medications because you don’t feel bad?'
- D. Can you tell me why you stopped taking the medication?'
Correct Answer: D
Rationale: Asking why the client stopped (D) is open-ended, identifying barriers like side effects (B) or asymptomatic disease (C). Financial issues (A) are secondary.
Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy?
- A. Heart failure.
- B. Activity intolerance.
- C. Powerlessness.
- D. Anticipatory grieving.
Correct Answer: A
Rationale: Cardiomyopathy impairs cardiac function, leading to heart failure (A) as the primary medical problem. Activity intolerance (B), powerlessness (C), and grieving (D) are secondary psychosocial issues.
The client comes to the emergency department saying, 'I am having a heart attack.' Which question is most pertinent when assessing the client?
- A. Can you describe your chest pain?'
- B. What were you doing when the pain started?'
- C. Did you have a high-fat meal today?'
- D. Does the pain get worse when you lie down?'
Correct Answer: A
Rationale: Describing chest pain (A) is most pertinent to differentiate cardiac from non-cardiac causes. Activity (B), diet (C), and positional pain (D) are secondary.