Nursing Elites

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. What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?

• A. Autoimmune disease
• B. Infectious disease
• C. Allergic reaction
• D. Degenerative disease

Correct answer: A

Rationale: The correct answer is A: Autoimmune disease. Autoimmune diseases occur when the body's immune system mistakenly attacks its own tissues, leading to inflammation and damage. This is different from infectious diseases (choice B), which are caused by pathogenic microorganisms, allergic reactions (choice C), which involve an exaggerated response of the immune system to harmless substances, and degenerative diseases (choice D), which are characterized by progressive deterioration of tissue or organs due to various factors.

3. The client on furosemide (Lasix) is at risk for which electrolyte imbalance?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypernatremia

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with diuretic use. Choices A, C, and D are incorrect. Hyperkalemia (choice A) is not typically associated with furosemide use. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels, not potassium levels affected by furosemide.

4. The client is receiving digoxin and complains of nausea. What is the nurse’s priority action?

• A. Check the client’s digoxin level.
• B. Continue the current dose of digoxin.
• C. Administer an antiemetic for nausea.
• D. Discontinue the digoxin immediately.

Correct answer: A

Rationale: The correct answer is to check the client’s digoxin level (Choice A). Nausea can be a sign of digoxin toxicity, so assessing the digoxin level is crucial to determine if the medication dosage needs adjustment. Continuing the current dose of digoxin (Choice B) may worsen the symptoms if toxicity is present. Administering an antiemetic (Choice C) may provide temporary relief but does not address the underlying issue of digoxin toxicity. Discontinuing digoxin immediately (Choice D) without assessing the digoxin level can be harmful if the medication is within the therapeutic range.

5. What is the term for the ability of cardiac cells to respond to a stimulus by initiating a cardiac impulse?

• A. Excitability
• B. Contractility
• C. Rhythmicity
• D. Conductivity

Correct answer: A

Rationale: The correct answer is A, Excitability. Excitability is the ability of cardiac cells to respond to a stimulus by initiating a cardiac impulse. Choice B, Contractility, refers to the ability of cardiac muscle to shorten forcibly. Choice C, Rhythmicity, refers to the cardiac muscle's ability to contract rhythmically. Choice D, Conductivity, refers to the ability of the heart's cells to conduct electrical impulses.

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