Nursing Elites

1. The client on warfarin has an INR of 1.2. What is the nurse’s priority action?

• A. Increase the dose of warfarin
• B. Administer vitamin K
• C. Monitor for signs of bleeding
• D. Hold the next dose and notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to increase the dose of warfarin. An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating that the dose is subtherapeutic. The priority action in this situation is to adjust the dose to achieve the target therapeutic INR range (usually 2-3) to prevent thromboembolic events. Administering vitamin K is not necessary as the INR is low, and there are no signs of bleeding. Monitoring for signs of bleeding is important but not the priority in this case since the INR is subtherapeutic. Holding the next dose and notifying the healthcare provider would delay the intervention needed to adjust the dose and achieve the therapeutic range.

2. The client is on a beta blocker for hypertension. What should the nurse monitor for?

• A. Bradycardia
• B. Tachycardia
• C. Hypertension
• D. Respiratory distress

Correct answer: A

Rationale: Corrected Rationale: When a client is on a beta blocker for hypertension, the nurse should monitor for bradycardia. Beta blockers are known to decrease heart rate, which can lead to bradycardia. Tachycardia (choice B) is unlikely as beta blockers have the opposite effect. Hypertension (choice C) is the condition being treated, not a side effect of beta blockers. Respiratory distress (choice D) is not a common effect of beta blockers and is not typically monitored in clients taking beta blockers.

3. What is a condition where a blood clot forms in a vein, often in the legs, which can cause pain and swelling and may lead to serious complications if it travels to the lungs?

• A. Deep vein thrombosis (DVT)
• B. Pulmonary embolism
• C. Varicose veins
• D. Aneurysm

Correct answer: A

Rationale: Deep vein thrombosis (DVT) is the correct answer. It is a condition where a blood clot forms in a deep vein, usually in the legs. If the clot breaks loose and travels to the lungs, it can cause a pulmonary embolism. Varicose veins are enlarged, twisted veins that are not typically associated with blood clots. Aneurysm is the abnormal swelling or bulging of a blood vessel.

4. Which term describes an abnormal heartbeat that can be either too fast or too slow?

• A. Arrhythmia
• B. Bradycardia
• C. Tachycardia
• D. Conductivity

Correct answer: A

Rationale: The correct answer is A: Arrhythmia. Arrhythmia is a broad term that refers to any irregularity in the heart's rhythm, which can manifest as a heartbeat that is too fast (tachycardia), too slow (bradycardia), or irregular. Choice B, Bradycardia, specifically denotes a slow heart rate, while choice C, Tachycardia, refers to a fast heart rate. Choice D, Conductivity, is not the correct term to describe an abnormal heartbeat characterized by speed irregularities.

5. The nurse is caring for a client on warfarin with an INR of 5.2. What is the most appropriate action?

• A. Administer vitamin K as an antidote.
• B. Hold the next dose of warfarin.
• C. Increase the dose of warfarin.
• D. Monitor the client’s INR closely.

Correct answer: A

Rationale: An INR of 5.2 is elevated, indicating an increased risk of bleeding. Administering vitamin K can help reverse the effects of warfarin, which is the most appropriate action in this situation. Holding the next dose of warfarin is not enough to address the high INR, and increasing the dose would further elevate the INR level. Monitoring the INR closely is important, but in this case, immediate action is needed to counteract the anticoagulant effects of warfarin.

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