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 term for a blood clot blocking an artery in the lungs, leading to symptoms like shortness of breath and chest pain?

• A. Pulmonary embolism
• B. Deep vein thrombosis (DVT)
• C. Myocardial infarction
• D. Pneumothorax

Correct answer: A

Rationale: The correct answer is A, pulmonary embolism. A pulmonary embolism occurs when a blood clot travels to the lungs and blocks an artery, causing symptoms like shortness of breath and chest pain. Choice B, deep vein thrombosis (DVT), involves a blood clot forming in a deep vein, usually in the legs. Choice C, myocardial infarction, refers to a heart attack due to blocked blood flow to the heart muscle. Choice D, pneumothorax, is a collapsed lung due to air leaking into the chest cavity.

3. Which heart chamber receives oxygenated blood from the lungs and pumps it to the rest of the body?

• A. Left atrium
• B. Right atrium
• C. Left ventricle
• D. Right ventricle

Correct answer: C

Rationale: The correct answer is the left ventricle. It receives oxygenated blood from the left atrium and pumps it to the rest of the body through the aorta. The left atrium receives oxygenated blood from the lungs, the right atrium receives deoxygenated blood from the body, and the right ventricle pumps deoxygenated blood to the lungs.

4. What is a condition where the lung's air sacs become inflamed and fill with fluid or pus, causing cough, fever, chills, and difficulty breathing?

• A. Pneumonia
• B. Tuberculosis
• C. Asthma
• D. Bronchitis

Correct answer: A

Rationale: Pneumonia is the correct answer. It is an infection that inflames the air sacs in one or both lungs, leading to the accumulation of fluid or pus, which results in symptoms such as cough, fever, chills, and difficulty breathing. Tuberculosis (choice B) is a bacterial infection affecting the lungs but does not typically cause the same acute symptoms as described. Asthma (choice C) is a chronic respiratory condition characterized by inflammation and narrowing of the airways, not specifically involving the air sacs. Bronchitis (choice D) is an inflammation of the bronchial tubes, not the air sacs in the lungs, and does not typically cause the same symptoms as pneumonia.

5. The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse’s priority action?

• A. Hold the spironolactone and notify the healthcare provider.
• B. Administer potassium supplements.
• C. Continue the spironolactone as ordered.
• D. Increase the dose of spironolactone.

Correct answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels. Therefore, the priority action is to withhold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further management. Option B is incorrect because administering potassium supplements would worsen the hyperkalemia. Option C is incorrect as continuing spironolactone can lead to a further increase in potassium levels. Option D is incorrect as increasing the dose of spironolactone would be inappropriate in the presence of elevated potassium levels.

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