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 procedure to remove fluid or air from the pleural space to help a patient breathe easier?

Correct answer: A

Rationale: Correct! Thoracentesis is the correct answer. It is a procedure where fluid or air is removed from the pleural space in the chest to help the patient breathe more easily. Bronchoscopy (choice B) is a procedure to visualize the airways, while Chest X-ray (choice C) and CT scan (choice D) are imaging tests and do not involve the removal of fluid or air from the pleural space.

3. What diagnostic procedure uses sound waves to create images of the heart and assess its structure and function?

Correct answer: A

Rationale: An echocardiogram is the correct answer because it is a diagnostic procedure that uses sound waves to create images of the heart, enabling doctors to assess its structure and function. This imaging technique is specifically designed for cardiac assessment. MRI (Choice B), CT scan (Choice C), and X-ray (Choice D) are imaging modalities that are not primarily used for detailed evaluation of the heart's structure and function, making them incorrect choices for this question.

4. Which term conceptualizes that the greater the myocardial fiber stretch, within physiologic limits, the more forceful the ventricular contraction, thereby increasing stroke volume?

Correct answer: A

Rationale: The correct answer is A, Frank-Starling’s Law. This law explains that within physiologic limits, the greater the stretch of myocardial fibers, the more forceful the ventricular contraction, leading to an increased stroke volume. Choice B, Automaticity, refers to the ability of cardiac cells to spontaneously generate electrical impulses. Choice C, Contractility, represents the intrinsic ability of the heart muscle to contract. Choice D, Excitability, refers to the ability of cardiac cells to respond to electrical stimuli.

5. What is an acute respiratory infection that inflames the alveoli in one or both lungs, causing them to fill with fluid or pus?

Correct answer: A

Rationale: Pneumonia is the correct answer because it is an acute respiratory infection that inflames the alveoli in one or both lungs, leading to the accumulation of fluid or pus. This condition presents with symptoms like cough, fever, and difficulty breathing. Bronchitis is the inflammation of the bronchial tubes, not the alveoli. Tuberculosis is a bacterial infection that primarily affects the lungs but does not always result in alveolar inflammation. Asthma is a chronic respiratory condition characterized by airway inflammation and narrowing, not alveolar inflammation.

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