a client with a history of atrial fibrillation is prescribed warfarin coumadin which laboratory value should the nurse monitor closely
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam

1. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.

2. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?

Correct answer: B

Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.

3. To reduce the risk of being named in a malpractice lawsuit, which action is most important for the nurse to take?

Correct answer: A

Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.

4. The nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?

Correct answer: C

Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.

5. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding is most concerning?

Correct answer: C

Rationale: The correct answer is C. Use of accessory muscles is the most concerning finding in a client with COPD experiencing an exacerbation. This indicates increased work of breathing and can be a sign of respiratory failure, requiring immediate intervention. Oxygen saturation of 90% is low but not as concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute can be within normal limits. Inspiratory crackles may be present in COPD due to airway inflammation but are not as concerning as the use of accessory muscles.

Similar Questions

A client with heart failure is prescribed furosemide (Lasix). Which assessment finding requires immediate intervention?
A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which laboratory value requires immediate intervention?
The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy. The client's serum blood potassium is elevated. Which finding requires immediate action by the nurse?
The nurse is caring for a client with chronic kidney disease (CKD). Which laboratory value should be reported to the healthcare provider immediately?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses