ATI RN
Cardiovascular System Exam Questions
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. Which medication is typically prescribed for the treatment of attention-deficit/hyperactivity disorder (ADHD)?
- A. Haloperidol
- B. Sertraline
- C. Methylphenidate
- D. Clozapine
Correct answer: C
Rationale: Methylphenidate is a central nervous system stimulant often prescribed to manage symptoms of ADHD. It works by increasing the activity of certain neurotransmitters in the brain, helping to improve focus, attention, and impulse control in individuals with ADHD. Haloperidol, Sertraline, and Clozapine are not typically used as first-line treatments for ADHD. Haloperidol is an antipsychotic used in conditions like schizophrenia, Sertraline is an antidepressant primarily for mood disorders, and Clozapine is an atypical antipsychotic for treatment-resistant schizophrenia.
3. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should consider taking a sleeping pill before bed each night.
- C. It must be difficult taking care of someone who is terminally ill.
- D. You are doing a great job taking care of your mother.
Correct answer: A
Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.
4. A client is diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder?
- A. Altered red blood cell production
- B. Altered production of lymph nodes
- C. Malignant exacerbation in the number of leukocytes
- D. Malignant proliferation of plasma cells within the bone
Correct answer: D
Rationale: Multiple myeloma is a type of cancer that involves the malignant proliferation of plasma cells, which are a type of white blood cell that produces antibodies. In multiple myeloma, these abnormal plasma cells accumulate in the bone marrow, where they interfere with the production of normal blood cells and lead to the formation of tumors in the bones. This can cause bone pain, fractures, anemia, and impaired immune function. The excessive production of abnormal antibodies can also result in kidney damage and other systemic complications.
5. After routine patient contact, how long should hand washing last at least?
- A. 30 seconds
- B. 1 minute
- C. 2 minutes
- D. 3 minutes
Correct answer: A
Rationale: Proper hand washing for 30 seconds is recommended after routine patient contact as it effectively removes pathogens. This duration ensures thorough cleaning without excessive time consumption, promoting infection control and prevention.
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