the client on warfarin has an inr of 12 what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam Questions And Answers

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

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 procedure where a catheter is used to open a blocked or narrowed coronary artery, often involving the placement of a stent?

Correct answer: A

Rationale: The correct answer is Angioplasty. Angioplasty is a procedure where a catheter is used to open a blocked or narrowed coronary artery, often involving the placement of a stent to keep the artery open and improve blood flow to the heart. Choice B, Valve replacement, is incorrect as it involves replacing a heart valve, not opening a blocked artery. Choice C, Stent placement, is similar to angioplasty but not as specific, as it does not involve the catheter-based procedure. Choice D, Coronary artery bypass graft (CABG), is a different procedure where blocked arteries are bypassed using a blood vessel from another part of the body.

3. What is the term for a condition where the lung collapses due to air leaking into the space between the lung and the chest wall?

Correct answer: A

Rationale: Pneumothorax is the correct answer for this question. Pneumothorax is the collapse of a lung caused by the presence of air in the pleural space between the lung and chest wall. This condition can lead to chest pain, shortness of breath, and may require emergency treatment such as chest tube insertion to remove the air. Pleural effusion is the accumulation of fluid in the pleural space, not air. Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. Pulmonary fibrosis is a condition characterized by scarring and thickening of lung tissue, not related to air leaking into the pleural space.

4. Which term describes a type of abnormal heart rhythm characterized by rapid and irregular beating of the atria?

Correct answer: A

Rationale: The correct answer is Atrial fibrillation. Atrial fibrillation is indeed a type of abnormal heart rhythm characterized by rapid and irregular beating of the atria. This condition can increase the risk of stroke and heart failure. Choice B, Ventricular fibrillation, is incorrect because it refers to a life-threatening arrhythmia that occurs in the ventricles, not the atria. Choice C, Atrial flutter, is incorrect as it describes a different type of atrial arrhythmia characterized by a regular but fast heartbeat. Choice D, Sinus tachycardia, is incorrect because it is a normal increase in heart rate originating from the sinus node, not an abnormal rhythm.

5. What test measures the electrical activity of the heart over a 24- or 48-hour period?

Correct answer: A

Rationale: The correct answer is A, Holter monitor. A Holter monitor is a portable device that continuously records the heart's electrical activity over 24 to 48 hours, aiding in the diagnosis of arrhythmias and other heart conditions. Choice B, an Electrocardiogram, provides a snapshot of the heart's electrical activity at a specific point in time, not over an extended period like a Holter monitor. Choice C, a Stress test, measures how the heart responds to physical activity and is not used for continuous monitoring of electrical activity. Choice D, a Chest X-ray, is used to visualize the structures of the chest, not to measure the heart's electrical activity.

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