the nurse is caring for a client on warfarin with an inr of 52 what is the most appropriate action
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Nursing Elites

ATI RN

Physical Exam Cardiovascular System

1. The nurse is caring for a client on warfarin with an INR of 5.2. What is the most appropriate action?

Correct answer: A

Rationale: An INR of 5.2 is elevated, indicating an increased risk of bleeding. Administering vitamin K can help reverse the effects of warfarin, which is the most appropriate action in this situation. Holding the next dose of warfarin is not enough to address the high INR, and increasing the dose would further elevate the INR level. Monitoring the INR closely is important, but in this case, immediate action is needed to counteract the anticoagulant effects of warfarin.

2. What is a condition where the pulmonary arteries become blocked by a blood clot, leading to chest pain, shortness of breath, and other symptoms?

Correct answer: A

Rationale: The correct answer is A, pulmonary embolism. Pulmonary embolism is a condition where a blood clot blocks one of the pulmonary arteries in the lungs, resulting in symptoms like chest pain, shortness of breath, and other related signs. Choices B, C, and D are incorrect because pneumothorax refers to a collapsed lung, pulmonary edema is the build-up of fluid in the lungs, and pulmonary hypertension is high blood pressure in the arteries of the lungs - none of which directly involve a blood clot blocking the pulmonary arteries.

3. What is an infection that causes inflammation in the air sacs of one or both lungs, which may fill with fluid or pus?

Correct answer: A

Rationale: The correct answer is A, Pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus, causing symptoms like cough, fever, chills, and difficulty breathing. Tuberculosis (B) is a bacterial infection that primarily affects the lungs but is caused by a different bacterium. Pleurisy (C) is inflammation of the tissues that line the lungs and chest cavity, not the air sacs. Pulmonary edema (D) is a condition where fluid accumulates in the lungs' air sacs but is often due to heart problems rather than an infection.

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

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.

5. What is the term for inflammation of the bronchial tubes, often leading to a persistent cough and mucus production?

Correct answer: A

Rationale: The correct answer is 'Bronchitis.' Bronchitis refers to the inflammation of the bronchial tubes, which can be acute or chronic, leading to symptoms like coughing and increased mucus production. Choice B, 'Asthma,' is a chronic condition characterized by inflammation and narrowing of the airways, often causing wheezing and shortness of breath. Choice C, 'Pneumonia,' is an infection that inflames air sacs in one or both lungs, leading to symptoms like fever, cough, and difficulty breathing. Choice D, 'Cystic fibrosis,' is a genetic disorder that affects the lungs and digestive system, causing mucus buildup and respiratory issues.

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