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 type of medication is used to reduce high blood pressure by relaxing the blood vessels?

Correct answer: A

Rationale: Calcium channel blockers are medications that reduce high blood pressure by relaxing the blood vessels, facilitating easier blood flow through the vessels. Beta-blockers work by reducing the heart rate and the heart's workload. ACE inhibitors help relax blood vessels by blocking the production of a chemical that narrows blood vessels. Diuretics help the body get rid of excess sodium and water to lower blood pressure, but they do not directly relax blood vessels like calcium channel blockers do.

3. The nurse is caring for a client on heparin. What is the most important lab value to monitor?

Correct answer: A

Rationale: The correct answer is A: aPTT. When a client is on heparin therapy, monitoring the aPTT is crucial. The aPTT helps assess the effectiveness of heparin in preventing blood clots and guides dose adjustments as needed. INR (Choice B) is more commonly used to monitor warfarin therapy. Platelet count (Choice C) is important to assess for potential bleeding disorders or thrombocytopenia but is not the primary lab value to monitor for heparin therapy. Hemoglobin (Choice D) is essential for assessing oxygen-carrying capacity but is not the most important lab value to monitor when a client is on heparin.

4. Which condition is characterized by a chronic cough that produces mucus, often caused by long-term exposure to irritants?

Correct answer: A

Rationale: Chronic bronchitis is the correct answer. It is characterized by a long-term cough with mucus production, often caused by smoking or prolonged exposure to irritants. Tuberculosis (choice B) is a bacterial infection that primarily affects the lungs but does not usually present with a chronic cough as the main symptom. Asthma (choice C) is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to wheezing and shortness of breath, but it does not typically cause chronic mucus production. Sinusitis (choice D) is inflammation of the sinuses and presents with symptoms like facial pain, nasal congestion, and post-nasal drip, but not specifically a chronic cough with mucus production.

5. The nurse is administering digoxin to a client with a heart rate of 45 bpm. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A heart rate of 45 bpm is already low, and digoxin can further decrease the heart rate, leading to serious complications like bradycardia or heart block. Administering the medication can exacerbate the bradycardia, hence it should be withheld. Increasing the dose of digoxin is contraindicated due to the client's low heart rate. Monitoring the heart rate alone without taking immediate action to withhold the medication is not the priority when faced with the risk of further lowering the heart rate.

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