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 does the PR interval measure?

• A. Time it takes for the electrical impulse to travel from the atria to the ventricles
• B. Measurement of ventricular depolarization
• C. Duration of ventricular repolarization
• D. Segment representing the time between ventricular depolarization and repolarization

Correct answer: A

Rationale: The PR interval measures the time it takes for the electrical impulse to travel from the atria to the ventricles. It is crucial in diagnosing heart rhythm disorders, as abnormalities in this interval can indicate conduction abnormalities between the atria and ventricles. Choices B, C, and D are incorrect. The QRS complex represents ventricular depolarization, the QT interval represents the duration of ventricular repolarization, and the ST segment represents the time between ventricular depolarization and repolarization.

3. Which valve opens during ventricular systole and closes during ventricular diastole?

• A. Aortic valve
• B. Pulmonary valve
• C. Mitral valve
• D. Tricuspid valve

Correct answer: B

Rationale: The correct answer is B: Pulmonary valve. The pulmonary valve opens during ventricular systole to allow blood to flow from the right ventricle into the pulmonary artery. The aortic valve opens during ventricular systole to allow blood to flow from the left ventricle into the aorta. The mitral valve and tricuspid valve are atrioventricular valves that open during ventricular diastole to allow blood to flow from the atria into the ventricles.

4. This heart condition is characterized by decreased cardiac output and tissue perfusion, which can lead to organ failure.

• A. Cardiogenic shock
• B. Myocardial infarction
• C. Endocarditis
• D. Pericarditis

Correct answer: A

Rationale: The correct answer is A: Cardiogenic shock. Cardiogenic shock is a severe condition characterized by the heart's inability to pump enough blood, leading to decreased cardiac output and tissue perfusion, which can result in organ failure. Choice B, Myocardial infarction, specifically refers to a blockage of blood flow to the heart muscle. Choices C and D, Endocarditis and Pericarditis, do not directly involve decreased cardiac output leading to organ failure, making them incorrect in the context of the symptoms described in the question.

5. When administering enoxaparin (Lovenox) to a client for DVT prophylaxis, what is the most important lab value to monitor?

• A. Platelet count
• B. PT/INR
• C. aPTT
• D. Hemoglobin

Correct answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin (Lovenox) for DVT prophylaxis, it is crucial to monitor the platelet count as enoxaparin can lead to thrombocytopenia, a decrease in platelet levels. Monitoring the platelet count helps in early detection of this potential adverse effect. Choices B, C, and D are incorrect because PT/INR, aPTT, and hemoglobin levels are not the most important lab values to monitor specifically for enoxaparin administration and DVT prophylaxis.

Similar Questions