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. The nurse is administering nitroglycerin IV to a client with chest pain. What is the most important parameter to monitor?

Correct answer: A

Rationale: The correct answer is A: Blood pressure. When administering nitroglycerin IV to a client with chest pain, monitoring blood pressure is crucial as nitroglycerin can cause significant hypotension. While heart rate, oxygen saturation, and respiratory rate are important parameters to assess, blood pressure takes precedence in this scenario due to the potential hypotensive effects of nitroglycerin.

3. Which surgical procedure involves opening or replacing a narrowed or blocked heart valve?

Correct answer: A

Rationale: Valve replacement is the correct answer because it specifically involves surgically replacing a damaged or diseased heart valve with a prosthetic valve to address narrowing or blockage, thereby improving blood flow and heart function. Angioplasty (choice B) is a procedure to widen narrowed or obstructed arteries, typically using a balloon catheter. Stent placement (choice C) involves inserting a mesh tube to support a weakened artery. Coronary bypass surgery (choice D) is a procedure to create new routes for blood flow to the heart muscle by bypassing blocked arteries.

4. What is a condition where the heart's electrical system malfunctions, leading to an irregular heartbeat or arrhythmia?

Correct answer: A

Rationale: The correct answer is A, Arrhythmia. Arrhythmia refers to an irregular heartbeat caused by the malfunction of the heart's electrical system. Bradycardia (choice B) is a condition characterized by a slow heart rate, while Tachycardia (choice C) is a condition characterized by a fast heart rate. Ventricular fibrillation (choice D) is a life-threatening arrhythmia where the heart's lower chambers quiver erratically.

5. What test measures the electrical activity of the heart and can detect heart rhythm problems?

Correct answer: A

Rationale: The correct answer is Electrocardiogram (ECG or EKG). An electrocardiogram is a test that measures the electrical activity of the heart and can detect irregularities in heart rhythm. Choices B, C, and D are incorrect because a chest X-ray, MRI, and CT scan do not specifically measure the electrical activity of the heart or detect heart rhythm problems.

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