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. Which valve prevents backflow of blood into the left ventricle from the aorta?

Correct answer: A

Rationale: The correct answer is Aortic valve. The aortic valve is positioned between the left ventricle and the aorta. It prevents blood from flowing back into the left ventricle after it has been pumped into the aorta. The mitral valve (Choice B) is located between the left atrium and the left ventricle, the tricuspid valve (Choice C) is between the right atrium and right ventricle, and the pulmonary valve (Choice D) is situated between the right ventricle and the pulmonary artery. Therefore, they are not responsible for preventing backflow from the aorta into the left ventricle.

3. The client is on spironolactone (Aldactone). What is the most important dietary instruction?

Correct answer: A

Rationale: The correct answer is to avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and can lead to hyperkalemia if too much potassium is consumed. Choices B, C, and D are incorrect because increasing intake of potassium-rich foods can worsen hyperkalemia, while avoiding foods high in sodium is not the primary concern when taking spironolactone.

4. What is a condition where the heart's valves do not function properly, leading to disrupted blood flow within the heart?

Correct answer: A

Rationale: Valvular heart disease is the correct answer. It occurs when the heart's valves malfunction, leading to disrupted blood flow within the heart. Myocarditis refers to inflammation of the heart muscle, not specifically related to valve function. Endocarditis is an infection of the inner lining of the heart chambers and valves, not necessarily caused by valve malfunction. Aneurysm is the abnormal bulging of a blood vessel, not directly related to heart valve function.

5. The client is on nitroglycerin patches. What should the nurse include in the client’s education?

Correct answer: A

Rationale: The correct answer is A: 'Rotate the application site with each new patch.' When educating a client using nitroglycerin patches, it is essential to rotate the application site to prevent skin irritation. Choice B is incorrect because applying the patch at the same time each day is not a critical aspect of patch application. Choice C is incorrect as nitroglycerin patches are usually left on for a specific period, typically 12 to 14 hours, before being replaced. Choice D is incorrect because applying the patch to the same site each time can lead to skin irritation and tolerance development.

Similar Questions

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What is a condition where the heart beats too slowly, reducing the amount of blood pumped to the body?
The nurse is giving nitroglycerin sublingually for chest pain. What is the most important instruction to give to the client?
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