Nursing Elites

1. What test measures the electrical activity of the heart over a period of time, typically 24 to 48 hours?

• A. Holter monitor
• B. Echocardiogram
• C. Stress test
• D. Arterial blood gas (ABG)

Correct answer: A

Rationale: The correct answer is A, Holter monitor. A Holter monitor is a portable device that records the electrical activity of the heart over a period of 24 to 48 hours. It is used to detect arrhythmias and other heart conditions. Choice B, Echocardiogram, is a test that uses sound waves to create images of the heart's structure and function, not focused on the electrical activity. Choice C, Stress test, evaluates the heart's function under stress but does not monitor electrical activity over an extended period. Choice D, Arterial blood gas (ABG), measures the levels of oxygen and carbon dioxide in the blood, unrelated to measuring the electrical activity of the heart over time.

2. The client is on warfarin and has an INR of 1.5. What is the nurse’s priority action?

• A. Increase the dose of warfarin.
• B. Hold the next dose of warfarin.
• C. Continue the current dose of warfarin.
• D. Monitor the client’s INR closely.

Correct answer: B

Rationale: An INR of 1.5 is below the therapeutic range for a client on warfarin, indicating that the client may be at risk of clot formation. The nurse's priority action should be to hold the next dose of warfarin to prevent further reduction of the INR. Increasing the dose could potentially lead to an increased risk of bleeding, and continuing the current dose may not be sufficient to bring the INR within the therapeutic range. Monitoring the client's INR closely is important but not the priority action in this scenario.

3. What test uses sound waves to create pictures of the heart, allowing doctors to see how well the heart is functioning?

• A. Echocardiogram
• B. MRI
• C. CT scan
• D. X-ray

Correct answer: A

Rationale: The correct answer is an echocardiogram. This test utilizes sound waves to generate images of the heart, enabling doctors to evaluate both the function and structure of the heart. Choice B, MRI, uses magnetic fields and radio waves to produce detailed images of the body's organs and structures, not specifically focused on the heart. Choice C, CT scan, employs X-rays to create detailed cross-sectional images of the body, not primarily for the heart. Choice D, X-ray, uses electromagnetic radiation to produce images of internal structures, but it does not provide the detailed pictures of the heart's function that an echocardiogram does.

4. The client on warfarin has an INR of 5.5. What is the priority nursing action?

• A. Administer vitamin K as an antidote.
• B. Hold the next dose of warfarin.
• C. Increase the dose of warfarin.
• D. Administer fresh frozen plasma.

Correct answer: A

Rationale: An INR of 5.5 is significantly elevated, indicating an increased risk of bleeding. The priority nursing action in this situation is to administer vitamin K as an antidote to reverse the effects of warfarin and lower the INR. Holding the next dose of warfarin (choice B) is important but not as immediate as administering vitamin K. Increasing the dose of warfarin (choice C) would further elevate the INR, worsening the bleeding risk. Administering fresh frozen plasma (choice D) is not the first-line treatment for high INR due to warfarin.

5. The nurse is monitoring a client on dobutamine. What adverse effect should the nurse watch for?

• A. Tachycardia
• B. Bradycardia
• C. Hypertension
• D. Respiratory distress

Correct answer: A

Rationale: The correct answer is A: Tachycardia. Dobutamine is a medication that stimulates beta-1 adrenergic receptors in the heart, leading to increased heart rate. Therefore, tachycardia is a common adverse effect that the nurse should monitor for. Choices B, C, and D are incorrect because dobutamine typically does not cause bradycardia, hypertension, or respiratory distress as its primary adverse effects.

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