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 condition refers to the heart being unable to pump sufficient blood to meet the body's needs?

• A. Heart failure
• B. Myocardial infarction
• C. Cardiomyopathy
• D. Pericarditis

Correct answer: A

Rationale: The correct answer is A, heart failure. This condition occurs when the heart can't pump enough blood to fulfill the body's requirements. Myocardial infarction (choice B) is the medical term for a heart attack, which is caused by a blockage in the coronary arteries. Cardiomyopathy (choice C) is a disease of the heart muscle that makes it harder for the heart to pump blood. Pericarditis (choice D) is the inflammation of the pericardium, the thin sac-like membrane surrounding the heart, and does not specifically involve the heart's inability to pump sufficient blood.

3. The client on spironolactone should avoid which of the following?

• A. Foods high in potassium
• B. Foods high in sodium
• C. Foods high in calcium
• D. Foods high in chloride

Correct answer: A

Rationale: The correct answer is A: Foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and excrete sodium. Consuming foods high in potassium while on spironolactone can lead to an excess of potassium in the body, potentially causing hyperkalemia. Choices B, C, and D are incorrect because spironolactone does not directly interact with sodium, calcium, or chloride in a way that would require specific dietary restrictions related to these minerals.

4. What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?

• A. Autoimmune disease
• B. Infectious disease
• C. Allergic reaction
• D. Degenerative disease

Correct answer: A

Rationale: The correct answer is A: Autoimmune disease. Autoimmune diseases occur when the body's immune system mistakenly attacks its own tissues, leading to inflammation and damage. This is different from infectious diseases (choice B), which are caused by pathogenic microorganisms, allergic reactions (choice C), which involve an exaggerated response of the immune system to harmless substances, and degenerative diseases (choice D), which are characterized by progressive deterioration of tissue or organs due to various factors.

5. What is the condition where the lungs become filled with fluid, often due to heart failure, making it difficult to breathe?

• A. Pulmonary edema
• B. Pleural effusion
• C. Pulmonary hypertension
• D. Pneumothorax

Correct answer: A

Rationale: Pulmonary edema is the correct answer. It occurs when fluid fills the lungs, usually due to heart failure, leading to breathing difficulties. Pleural effusion is the accumulation of fluid around the lungs, not inside. Pulmonary hypertension is high blood pressure in the arteries of the lungs, and pneumothorax is the presence of air between the lung and chest wall.

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