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. 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.

3. This is the inflammation of the heart's inner lining, usually caused by an infection.

Correct answer: A

Rationale: Endocarditis is the inflammation of the inner lining of the heart's chambers and valves, usually caused by a bacterial infection. Myocarditis is the inflammation of the heart muscle, Pericarditis is the inflammation of the pericardium (the outer lining of the heart), and Valvulitis is the inflammation of the heart valves. Therefore, in this case, the correct answer is Endocarditis as it specifically refers to the inflammation of the heart's inner lining.

4. What is a condition characterized by the presence of air or gas in the pleural space, leading to the collapse of the lung?

Correct answer: A

Rationale: The correct answer is Pneumothorax. Pneumothorax occurs when air or gas accumulates in the pleural space, causing the lung to collapse. This condition can result in symptoms such as chest pain and difficulty breathing. Pulmonary embolism (choice B) is a blockage in one of the pulmonary arteries in the lungs, usually caused by a blood clot. Pleural effusion (choice C) is the accumulation of excess fluid in the pleural space, not air or gas. Atelectasis (choice D) refers to the collapse or closure of a lung resulting in reduced or absent gas exchange.

5. What is the term for a condition where the lung collapses due to air leaking into the space between the lung and the chest wall?

Correct answer: A

Rationale: Pneumothorax is the correct answer for this question. Pneumothorax is the collapse of a lung caused by the presence of air in the pleural space between the lung and chest wall. This condition can lead to chest pain, shortness of breath, and may require emergency treatment such as chest tube insertion to remove the air. Pleural effusion is the accumulation of fluid in the pleural space, not air. Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. Pulmonary fibrosis is a condition characterized by scarring and thickening of lung tissue, not related to air leaking into the pleural space.

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