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 term refers to the relaxation phase of the heart, during which the chambers fill with blood?

• A. Diastole
• B. Systole
• C. Refractoriness
• D. Automaticity

Correct answer: A

Rationale: The correct answer is A, Diastole. Diastole is the phase of the cardiac cycle when the heart muscles relax, allowing the chambers to fill with blood. Choice B, Systole, is incorrect as systole is the contraction phase of the heart when blood is pumped out of the chambers. Choice C, Refractoriness, refers to a period during which the heart muscle is unresponsive to stimuli. Choice D, Automaticity, relates to the heart's ability to generate its own electrical impulses.

3. The client is being taught about the use of warfarin. What is the most important dietary instruction?

• A. Avoid foods high in vitamin K.
• B. Increase the intake of vitamin K-rich foods.
• C. Avoid foods high in protein.
• D. Increase the intake of foods high in calcium.

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is a medication that works by decreasing the activity of vitamin K in the body to prevent blood clotting. Therefore, consuming foods high in vitamin K like green leafy vegetables can interfere with the medication's effectiveness. Choices B, C, and D are incorrect. Increasing the intake of vitamin K-rich foods would counteract the effects of warfarin. Avoiding foods high in protein or increasing the intake of foods high in calcium are not specifically related to the use of warfarin.

4. Which condition is an infection that inflames the air sacs in one or both lungs, which may fill with fluid?

• A. Pneumonia
• B. Bronchitis
• C. Tuberculosis
• D. Cystic fibrosis

Correct answer: A

Rationale: The correct answer is A, Pneumonia. Pneumonia is an infection that inflames the air sacs in the lungs, which may fill with fluid or pus, causing symptoms like cough, fever, and difficulty breathing. Bronchitis (choice B) is an inflammation of the bronchial tubes, not the air sacs in the lungs. Tuberculosis (choice C) is a bacterial infection that primarily affects the lungs but does not always cause fluid accumulation in the air sacs. Cystic fibrosis (choice D) is a genetic disorder that affects the lungs but does not directly cause inflammation of the air sacs with fluid.

5. The client is on amiodarone and reports blurred vision. What is the nurse’s best response?

• A. Reassure the client that this is a common side effect.
• B. Instruct the client to report this symptom to the healthcare provider immediately.
• C. Advise the client to stop taking the medication.
• D. Discontinue the amiodarone immediately.

Correct answer: B

Rationale: Blurred vision is a potential side effect of amiodarone. Instructing the client to report this symptom to the healthcare provider immediately is the most appropriate response. Choice A is incorrect because although blurred vision can be a common side effect of amiodarone, it should not be dismissed without further evaluation. Choice C is incorrect as advising the client to stop taking the medication without consulting the healthcare provider can be dangerous and is not the first course of action. Choice D is too drastic as discontinuing the medication should be done under the guidance of a healthcare provider after proper evaluation.

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