the client is on warfarin and has an inr of 15 what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam Questions

1. The client is on warfarin and has an INR of 1.5. What is the nurse’s priority action?

Correct answer: B

Rationale: An INR of 1.5 is below the therapeutic range for a client on warfarin, indicating that the client may be at risk of clot formation. The nurse's priority action should be to hold the next dose of warfarin to prevent further reduction of the INR. Increasing the dose could potentially lead to an increased risk of bleeding, and continuing the current dose may not be sufficient to bring the INR within the therapeutic range. Monitoring the client's INR closely is important but not the priority action in this scenario.

2. What is the narrowing of the arteries due to the buildup of plaque, which can lead to heart attacks and strokes?

Correct answer: A

Rationale: Coronary artery disease is the correct answer. It is the narrowing or blockage of the coronary arteries due to plaque buildup, which can lead to heart attacks and other cardiovascular issues. Choice B, Peripheral artery disease, involves the narrowing of arteries in the limbs, not specifically the coronary arteries. Choice C, Aortic stenosis, refers to the narrowing of the aortic valve opening, not the arteries. Choice D, Mitral valve prolapse, is a condition where the valve between the left atrium and left ventricle doesn't close properly, unrelated to arterial narrowing.

3. The client is on nitroglycerin patches. What should the nurse include in the client’s education?

Correct answer: A

Rationale: The correct answer is A: 'Rotate the application site with each new patch.' When educating a client using nitroglycerin patches, it is essential to rotate the application site to prevent skin irritation. Choice B is incorrect because applying the patch at the same time each day is not a critical aspect of patch application. Choice C is incorrect as nitroglycerin patches are usually left on for a specific period, typically 12 to 14 hours, before being replaced. Choice D is incorrect because applying the patch to the same site each time can lead to skin irritation and tolerance development.

4. The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?

Correct answer: B

Rationale: The correct answer is to give Digibind as an antidote in cases of severe digoxin toxicity. Digibind works by binding to digoxin and preventing it from causing further harm. Checking the potassium level (choice A) is important but not the priority when the client has severe toxicity. Changing the dosing to every other day (choice C) is not appropriate in the setting of severe toxicity where immediate action is required. Giving a potassium supplement (choice D) may be needed eventually, but the priority is to administer Digibind to counteract the toxic effects of digoxin.

5. Which chronic condition is characterized by abnormally thickened heart muscle, making it harder for the heart to pump blood efficiently?

Correct answer: A

Rationale: Hypertrophic cardiomyopathy is the correct answer. In this condition, the heart muscle becomes abnormally thickened, leading to difficulties in pumping blood efficiently. Dilated cardiomyopathy (choice B) involves the enlargement of the heart chambers, not thickening of the heart muscle. Restrictive cardiomyopathy (choice C) is characterized by stiffening of the heart muscle, impairing its ability to fill properly. Ventricular hypertrophy (choice D) refers to the thickening of the heart's ventricle walls, which can result from various conditions, not solely hypertrophic cardiomyopathy.

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