Nursing Elites

1. The client on warfarin has an INR of 4.5. What is the most appropriate action by the nurse?

• A. Administer vitamin K.
• 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 4.5 is elevated, indicating an increased risk of bleeding due to excessive anticoagulation. The most appropriate action for the nurse in this scenario is to administer vitamin K. Vitamin K helps reverse the anticoagulant effects of warfarin, thus lowering the INR and reducing the risk of bleeding. Holding the next dose of warfarin (choice B) is not sufficient to address the immediate high INR level. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the risk of bleeding. While monitoring the client's INR closely (choice D) is important, immediate action is required to address the critically high INR level, making the administration of vitamin K the priority intervention.

2. What is a severe allergic reaction that can cause difficulty breathing and shock?

• A. Anaphylaxis
• B. Asthma attack
• C. Bronchospasm
• D. Hypersensitivity

Correct answer: A

Rationale: Anaphylaxis is the correct answer. It is a severe, potentially life-threatening allergic reaction that can lead to difficulty breathing, low blood pressure, and loss of consciousness. An asthma attack is a separate condition characterized by narrowed airways and difficulty breathing, but it is not necessarily related to an allergic reaction like anaphylaxis. Bronchospasm refers to the sudden constriction of muscles in the bronchi, leading to breathing difficulties, and is not specific to allergic reactions. Hypersensitivity is a general term for an exaggerated immune response to a substance, which may or may not manifest as severe allergic reactions like anaphylaxis.

3. This is a procedure where a small mesh tube is inserted into an artery to keep it open and improve blood flow.

• A. Stent placement
• B. Angioplasty
• C. Bypass surgery
• D. Coronary artery bypass graft (CABG)

Correct answer: A

Rationale: Stent placement is a procedure where a small mesh tube (stent) is inserted into an artery to keep it open and improve blood flow, often following angioplasty.

4. What type of medication is used to relax the muscles around the airways and improve breathing in conditions like asthma and COPD?

• A. Bronchodilator
• B. Corticosteroid
• C. Mucolytic
• D. Antihistamine

Correct answer: A

Rationale: Bronchodilators are medications that relax the muscles around the airways, improving airflow and making breathing easier for patients with asthma or COPD. Corticosteroids are anti-inflammatory drugs used to reduce airway inflammation, while mucolytics help in thinning and clearing mucus. Antihistamines are used to treat allergies and not specifically to improve breathing in conditions like asthma or COPD.

5. The client on nitroglycerin complains of a headache. What is the most appropriate response by the nurse?

• A. Administer acetaminophen as prescribed for the headache.
• B. Hold the next dose of nitroglycerin.
• C. Discontinue the nitroglycerin immediately.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: The correct response is to administer acetaminophen as prescribed for the headache. Headaches are a common side effect of nitroglycerin due to vasodilation. Administering acetaminophen can help relieve the headache. Holding the next dose of nitroglycerin (Choice B) may not address the current headache, and discontinuing nitroglycerin immediately (Choice C) without healthcare provider guidance can be dangerous due to the potential for rebound hypertension. Notifying the healthcare provider immediately (Choice D) is not necessary for a common side effect like a headache, and the nurse can manage this symptom independently.

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