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 type of heart valve disease occurs when the mitral valve does not close properly, allowing blood to flow backward into the left atrium?

Correct answer: A

Rationale: Mitral regurgitation is the correct answer. It occurs when the mitral valve does not close properly, allowing blood to flow backward into the left atrium. This condition can lead to symptoms such as fatigue, shortness of breath, and if left untreated, it can progress to heart failure. Aortic stenosis (choice B) is a different heart valve condition characterized by narrowing of the aortic valve, restricting blood flow from the heart. Tricuspid regurgitation (choice C) involves the tricuspid valve not closing properly, leading to blood flowing back into the right atrium. Pulmonary hypertension (choice D) is a condition characterized by high blood pressure in the arteries of the lungs.

3. What is a condition where a blood clot forms in a vein, often in the legs, which can cause pain and swelling and may lead to serious complications if it travels to the lungs?

Correct answer: A

Rationale: Deep vein thrombosis (DVT) is the correct answer. It is a condition where a blood clot forms in a deep vein, usually in the legs. If the clot breaks loose and travels to the lungs, it can cause a pulmonary embolism. Varicose veins are enlarged, twisted veins that are not typically associated with blood clots. Aneurysm is the abnormal swelling or bulging of a blood vessel.

4. What is a life-threatening condition where the heart suddenly stops beating?

Correct answer: A

Rationale: Cardiac arrest is the correct answer. It is a sudden, unexpected loss of heart function, breathing, and consciousness, typically resulting in death if not treated immediately. Myocardial infarction (choice B) refers to a heart attack caused by a blockage in the coronary arteries. Heart failure (choice C) is a chronic condition where the heart is unable to pump blood efficiently. Atrial fibrillation (choice D) is an irregular and often rapid heart rate that can lead to complications but is not the same as cardiac arrest.

5. The client has a prescription for sublingual nitroglycerin. What is the nurse's instruction for how to take this medication during an episode of chest pain?

Correct answer: A

Rationale: The correct answer is A. The standard instruction for sublingual nitroglycerin during an episode of chest pain is to take one tablet every 5 minutes, up to three tablets. If the pain persists after taking three tablets, the client should seek emergency help. Choice B is incorrect because taking one tablet every hour is not the appropriate dosing for acute chest pain. Choice C is incorrect as taking two tablets immediately is not in line with the recommended dosing instructions. Choice D is incorrect because sublingual nitroglycerin should be placed under the tongue, not swallowed with water.

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