Priority nursing interventions when a client is being given warfarin include what?

Correct Answer: D

Rationale: The correct answer is D: Monitor the INR. The International Normalized Ratio (INR) is crucial for monitoring warfarin therapy as it assesses the client's clotting time. INR values within the therapeutic range indicate the efficacy and safety of warfarin. Monitoring blood pressure (A) is important but not a priority for warfarin therapy. Monitoring vitamin K level (B) is unnecessary as warfarin inhibits vitamin K-dependent clotting factors. Monitoring warfarin level (C) is not routinely done as INR is a more accurate reflection of its effect.

Correct Answer: C

Rationale: The correct answer is C: Active gallbladder disease. Gemfibrozil can exacerbate gallbladder disease by increasing the risk of gallstones. This can lead to complications such as cholecystitis. Therefore, clients with active gallbladder disease should be cautious when taking gemfibrozil. A: History of MI - This is not a contraindication for gemfibrozil. In fact, gemfibrozil can be beneficial for clients with a history of MI by helping to lower triglyceride levels and reduce the risk of cardiovascular events. B: History of elevated triglyceride levels - This is not a contraindication for gemfibrozil. In fact, gemfibrozil is indicated for the treatment of elevated triglyceride levels. D: Taking aspirin with gemfibrozil - While there can be interactions between aspirin and gemfibrozil, it is not a contraindication. Clients may need to be monitored for

Correct Answer: D

Rationale: The correct answer is D: Between the S2 and the S1 beat. A diastolic murmur is heard during the relaxing phase of the heart cycle, between the closure of the aortic valve (S2) and the mitral valve (S1) opening. This indicates a problem with the heart valves during diastole. Choices A, B, and C do not align with the timing of diastolic murmurs in the cardiac cycle and are therefore incorrect.

Correct Answer: C

Rationale: The correct answer is C: Type 1 second degree AV block. This rhythm is characterized by a slightly irregular rhythm and P waves that come in multiples, known as "grouped beating." In Type 1 AV block, there is a progressive lengthening of the PR interval until a QRS complex is dropped. This is consistent with the description provided in the question. A: Third degree AV block is characterized by complete dissociation between the atria and ventricles, resulting in an atrial rate that is typically faster than the ventricular rate. This is not the case in the scenario described. B: Type 2 second degree AV block is characterized by intermittent failure of conduction of P waves to the ventricles, resulting in dropped QRS complexes. This is not consistent with the description provided. D: Junctional escape rhythm is characterized by an escape rhythm originating from the AV junction, resulting in a heart rate of 40-60 bpm. This is not the rhythm described

Correct Answer: D

Rationale: The correct answer is D because the fact that the pain goes away after taking a nitroglycerin tablet is a classic characteristic of chronic stable angina. Nitroglycerin is a vasodilator that helps relieve angina by increasing blood flow to the heart. This response is specific to angina and indicates that the pain is likely due to coronary artery disease. A: "The pain wakes me up at night" is not specific to angina and could indicate other issues like gastroesophageal reflux disease. B: "The pain is level 3 to 5" is subjective and doesn't provide diagnostic value for angina. C: "The pain has gotten worse over the last week" may suggest a change in condition but doesn't confirm the diagnosis of chronic stable angina.