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. Which of the following is a chronic lung disease that includes conditions such as chronic bronchitis and emphysema, characterized by obstructed airflow from the lungs?

• A. Chronic obstructive pulmonary disease (COPD)
• B. Pulmonary fibrosis
• C. Asthma
• D. Pneumonia

Correct answer: A

Rationale: The correct answer is A, Chronic obstructive pulmonary disease (COPD). COPD is a chronic lung disease that encompasses conditions like chronic bronchitis and emphysema. These conditions lead to obstructed airflow from the lungs, causing symptoms such as cough, shortness of breath, and wheezing. Choice B, Pulmonary fibrosis, involves scarring of the lung tissue, leading to breathing difficulties but is not specifically characterized by obstructed airflow like COPD. Asthma (Choice C) is a chronic condition characterized by airway inflammation and bronchoconstriction, not always resulting in obstructed airflow. Pneumonia (Choice D) is an acute infection of the lung tissue, causing symptoms like fever, cough, and difficulty breathing, but is not a chronic condition like COPD.

3. Which valve opens during ventricular systole and closes during ventricular diastole?

• A. Aortic valve
• B. Pulmonary valve
• C. Mitral valve
• D. Tricuspid valve

Correct answer: B

Rationale: The correct answer is B: Pulmonary valve. The pulmonary valve opens during ventricular systole to allow blood to flow from the right ventricle into the pulmonary artery. The aortic valve opens during ventricular systole to allow blood to flow from the left ventricle into the aorta. The mitral valve and tricuspid valve are atrioventricular valves that open during ventricular diastole to allow blood to flow from the atria into the ventricles.

4. The nurse is giving digoxin to a client. What is the most important parameter to check before administration?

• A. Heart rate
• B. Blood pressure
• C. Respiratory rate
• D. Oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Heart rate. Before administering digoxin, it is crucial to check the client's heart rate because digoxin can cause bradycardia, an abnormally slow heart rate. Monitoring the heart rate is essential to prevent potential complications associated with digoxin therapy. Choices B, C, and D are less critical parameters to assess before administering digoxin. While blood pressure is also important to monitor during digoxin therapy, the most crucial parameter to check due to the medication's potential effect on heart rate is the heart rate itself.

5. The client on nitroglycerin complains of a headache. How does the nurse explain this?

• A. This is a normal side effect of nitroglycerin.
• B. This is an allergic reaction to nitroglycerin.
• C. This is an indication of overdose.
• D. This is a sign of heart failure.

Correct answer: A

Rationale: The correct answer is A: 'This is a normal side effect of nitroglycerin.' Headaches are a common side effect of nitroglycerin due to vasodilation. Choice B is incorrect because allergic reactions to nitroglycerin typically present with symptoms like rash, itching, or shortness of breath. Choice C is incorrect as an overdose of nitroglycerin would likely present with symptoms beyond just a headache. Choice D is incorrect because headaches related to nitroglycerin are not indicative of heart failure.

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