Nursing Elites

1. The client on warfarin has an INR of 5.5. What is the priority nursing action?

• A. Administer vitamin K as an antidote.
• B. Hold the next dose of warfarin.
• C. Increase the dose of warfarin.
• D. Administer fresh frozen plasma.

Correct answer: A

Rationale: An INR of 5.5 is significantly elevated, indicating an increased risk of bleeding. The priority nursing action in this situation is to administer vitamin K as an antidote to reverse the effects of warfarin and lower the INR. Holding the next dose of warfarin (choice B) is important but not as immediate as administering vitamin K. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the bleeding risk. Administering fresh frozen plasma (choice D) is not the first-line treatment for high INR due to warfarin.

2. What is a genetic disorder that affects the lungs and digestive system, leading to thick, sticky mucus that can clog the airways?

• A. Cystic fibrosis
• B. COPD
• C. Bronchiectasis
• D. Pulmonary fibrosis

Correct answer: A

Rationale: The correct answer is A, cystic fibrosis. Cystic fibrosis is a genetic disorder that primarily affects the lungs and digestive system. It leads to the production of thick, sticky mucus that can clog the airways, causing respiratory issues. Choice B, COPD (Chronic Obstructive Pulmonary Disease), is a different condition usually caused by smoking or exposure to irritants. Choice C, bronchiectasis, involves the widening and scarring of the airways, not the production of thick mucus. Choice D, pulmonary fibrosis, is a lung disease characterized by scarring of the lung tissue, not excessive mucus production.

3. Which condition is characterized by the sudden onset of shortness of breath, often occurring at night and associated with heart failure?

• A. Paroxysmal nocturnal dyspnea
• B. Sleep apnea
• C. Orthopnea
• D. Dyspnea

Correct answer: A

Rationale: Paroxysmal nocturnal dyspnea is the correct answer. It is characterized by the sudden onset of shortness of breath during sleep, often associated with heart failure. Choice B, Sleep apnea, involves pauses in breathing during sleep but is not specifically associated with heart failure. Choice C, Orthopnea, is difficulty breathing that occurs when lying down and is relieved by sitting up, not necessarily associated with heart failure. Choice D, Dyspnea, is a general term for difficulty breathing and does not specifically describe the sudden onset at night associated with heart failure as seen in paroxysmal nocturnal dyspnea.

4. What is a condition where the heart's valves do not function properly, leading to disrupted blood flow within the heart?

• A. Valvular heart disease
• B. Myocarditis
• C. Endocarditis
• D. Aneurysm

Correct answer: A

Rationale: Valvular heart disease is the correct answer. It occurs when the heart's valves malfunction, leading to disrupted blood flow within the heart. Myocarditis refers to inflammation of the heart muscle, not specifically related to valve function. Endocarditis is an infection of the inner lining of the heart chambers and valves, not necessarily caused by valve malfunction. Aneurysm is the abnormal bulging of a blood vessel, not directly related to heart valve function.

5. The healthcare provider is monitoring a client on an ACE inhibitor. What lab value is most important to monitor?

• A. Potassium
• B. Sodium
• C. Creatinine
• D. Calcium

Correct answer: A

Rationale: The correct answer is A: Potassium. When a client is on an ACE inhibitor, it is crucial to monitor potassium levels because ACE inhibitors can lead to an increase in potassium, potentially causing hyperkalemia. Monitoring sodium levels (Choice B) is not as critical in this scenario. Creatinine levels (Choice C) are important for assessing kidney function but are not the most crucial lab value to monitor with ACE inhibitors. Calcium levels (Choice D) are not directly affected by ACE inhibitors and are not the priority for monitoring in this case.

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