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 type of medication that helps to prevent blood clots by thinning the blood?

Correct answer: A

Rationale: Anticoagulants are medications specifically designed to prevent blood clots by thinning the blood. They work by interfering with the body's blood clotting process. Beta-blockers, ACE inhibitors, and calcium channel blockers are medications used for different purposes such as managing blood pressure, heart conditions, and regulating heart rhythm, respectively. However, they do not have the primary function of preventing blood clots like anticoagulants.

3. What procedure is used to visualize the airways and diagnose lung disease?

Correct answer: A

Rationale: Bronchoscopy is the correct answer because it is a procedure specifically designed to visualize the airways and diagnose lung diseases by allowing doctors to examine the inside of the airways. Thoracentesis involves the removal of fluid from the pleural space around the lungs, not the airways. Pulmonary function tests assess how well the lungs work but do not visualize the airways directly. A chest X-ray provides an image of the lungs and surrounding structures but does not involve direct visualization of the airways.

4. Which type of medication helps to reduce the workload on the heart by slowing down the heart rate?

Correct answer: A

Rationale: Beta-blockers are medications that work by blocking the action of hormones like adrenaline, thereby reducing the heart rate and the workload on the heart. This makes them effective in managing high blood pressure and various heart conditions. Calcium channel blockers work by relaxing blood vessels and reducing the heart's workload, but they do not primarily slow down the heart rate. Diuretics help the body get rid of excess salt and water by increasing urine production, which can lower blood pressure but not by slowing down the heart rate. ACE inhibitors work by relaxing blood vessels, not by directly affecting heart rate.

5. From where do these originate, behind the cusps of the aortic valve, in an area known as Valsalva’s sinus?

Correct answer: B

Rationale: The correct answer is B, Aortic valve. The aortic valve is a semilunar valve located between the left ventricle and the aorta. It prevents the backflow of blood from the aorta into the left ventricle. The pulmonary valve (choice A) is located between the right ventricle and the pulmonary artery, not in the Valsalva’s sinus area. The tricuspid valve (choice C) is situated between the right atrium and right ventricle, and the mitral valve (choice D) is located between the left atrium and left ventricle, making them incorrect choices for this question.

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