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 furosemide (Lasix) and has a potassium level of 2.9 mEq/L. What is the nurse’s priority action?

• A. Administer potassium supplements.
• B. Hold the furosemide and notify the healthcare provider.
• C. Continue the current dose of furosemide.
• D. Decrease the dose of furosemide.

Correct answer: A

Rationale: The correct answer is A: Administer potassium supplements. A potassium level of 2.9 mEq/L indicates hypokalemia (low potassium levels). Furosemide (Lasix) is a loop diuretic that can cause potassium loss. Therefore, the priority action is to administer potassium supplements to correct the imbalance. Option B is incorrect because holding the furosemide without addressing the low potassium level could further worsen the imbalance. Option C is incorrect as continuing the current dose of furosemide without addressing the low potassium level could lead to complications. Option D is incorrect because decreasing the dose of furosemide does not directly address the low potassium level that needs immediate correction.

3. What test measures the pressure inside the arteries as the heart pumps blood?

• A. Blood pressure test
• B. Pulse oximetry
• C. Echocardiogram
• D. Spirometry

Correct answer: A

Rationale: The correct answer is A) Blood pressure test. A blood pressure test is specifically designed to measure the pressure inside the arteries as the heart pumps blood. This test is crucial in providing information about cardiovascular health by determining the force of blood against the artery walls. Choice B, Pulse oximetry, measures oxygen saturation in the blood, not blood pressure. Choice C, Echocardiogram, is an ultrasound test that evaluates the structure and function of the heart, not specifically blood pressure. Choice D, Spirometry, is a test used to assess lung function, not blood pressure.

4. The healthcare provider is monitoring a client receiving lidocaine IV. What side effect is the healthcare provider most concerned about?

• A. Severe headache
• B. Nausea and vomiting
• C. Seizures
• D. Tremors

Correct answer: C

Rationale: Seizures are the most concerning side effect of lidocaine IV administration due to its potential to indicate lidocaine toxicity, which can lead to serious complications such as cardiovascular collapse. Headache, nausea, and tremors are not typically associated with lidocaine IV and are less concerning compared to seizures in this context.

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

• A. Rotate the application site with each new patch.
• B. Apply the patch at the same time each day.
• C. Leave the patch on for 24 hours, then remove it for 12 hours before applying a new one.
• D. Apply the patch to the same site each time.

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.

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