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?
- A. Administer vitamin K as an antidote.
- 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 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. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will mix the medication with applesauce
- B. I will provide a snack with the medication
- C. I will store the medication in the refrigerator
- D. I will swab the inside of my child's mouth with the medication
Correct answer: D
Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.
3. Which of the following tests is most commonly used to diagnose cholecystitis?
- A. Abdominal CT scan
- B. Abdominal ultrasound
- C. Barium swallow
- D. Endoscopy
Correct answer: B
Rationale: An abdominal ultrasound is the most commonly used test to diagnose cholecystitis.
4. As Leda’s nurse, you plan to set up an emergency equipment at her beside following thyroidectomy. You should include:
- A. An airway and rebreathing tube
- B. A tracheostomy set and oxygen
- C. A crush cart with bed board
- D. Two ampules of sodium bicarbonate
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
5. What is a major goal for home care nurses?
- A. Restoring maximum health function.
- B. Promoting the health of populations.
- C. Minimizing the progress of disease.
- D. Maintaining the health of populations.
Correct answer: A
Rationale: A major goal for home care nurses is restoring maximum health function. This involves helping patients achieve their highest level of health and independence, focusing on individualized care plans tailored to each patient's needs. Choice B, promoting the health of populations, is more aligned with public health nursing rather than home care nursing. Choice C, minimizing the progress of disease, is important but not as comprehensive as restoring maximum health function. Choice D, maintaining the health of populations, is more about preventive care at a population level rather than the individualized care provided by home care nurses.
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