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. What is the condition where the lungs become filled with fluid, often due to heart failure, making it difficult to breathe?

• A. Pulmonary edema
• B. Pleural effusion
• C. Pulmonary hypertension
• D. Pneumothorax

Correct answer: A

Rationale: Pulmonary edema is the correct answer. It occurs when fluid fills the lungs, usually due to heart failure, leading to breathing difficulties. Pleural effusion is the accumulation of fluid around the lungs, not inside. Pulmonary hypertension is high blood pressure in the arteries of the lungs, and pneumothorax is the presence of air between the lung and chest wall.

3. What is a condition where the heart muscle becomes thickened without an obvious cause, leading to a reduction in the heart's ability to pump blood?

• A. Hypertrophic cardiomyopathy
• B. Dilated cardiomyopathy
• C. Restrictive cardiomyopathy
• D. Myocarditis

Correct answer: A

Rationale: Hypertrophic cardiomyopathy is the correct answer. It is a condition characterized by the abnormal thickening of the heart muscle without an obvious cause, which impairs the heart's ability to effectively pump blood. Dilated cardiomyopathy (choice B) involves the enlargement and weakening of the heart chambers, not thickening. Restrictive cardiomyopathy (choice C) refers to the stiffening of the heart muscle, limiting its ability to fill properly. Myocarditis (choice D) is inflammation of the heart muscle usually caused by a viral infection, not thickening.

4. The client on nitroglycerin complains of a headache. How does the nurse explain this?

• A. This is a normal side effect of nitroglycerin.
• B. This is an allergic reaction to nitroglycerin.
• C. This is an indication of overdose.
• D. This is a sign of heart failure.

Correct answer: A

Rationale: The correct answer is A: 'This is a normal side effect of nitroglycerin.' Headaches are a common side effect of nitroglycerin due to vasodilation. Choice B is incorrect because allergic reactions to nitroglycerin typically present with symptoms like rash, itching, or shortness of breath. Choice C is incorrect as an overdose of nitroglycerin would likely present with symptoms beyond just a headache. Choice D is incorrect because headaches related to nitroglycerin are not indicative of heart failure.

5. Which heart chamber receives oxygenated blood from the lungs and pumps it to the rest of the body?

• A. Left atrium
• B. Right atrium
• C. Left ventricle
• D. Right ventricle

Correct answer: C

Rationale: The correct answer is the left ventricle. It receives oxygenated blood from the left atrium and pumps it to the rest of the body through the aorta. The left atrium receives oxygenated blood from the lungs, the right atrium receives deoxygenated blood from the body, and the right ventricle pumps deoxygenated blood to the lungs.

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