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

Correct Answer: B

Rationale: The correct answer is B: Hold the next dose of warfarin. With an INR of 1.5, the client's blood is not adequately anticoagulated, increasing the risk of blood clots. Holding the next dose will prevent further thinning of blood and allow the INR to increase to the target range. Increasing the dose (A) could lead to over-anticoagulation, risking bleeding. Continuing the current dose (C) maintains inadequate anticoagulation. Monitoring (D) is important, but the immediate action should be to hold the next dose.

Correct Answer: A

Rationale: The correct answer is A: Cough. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a common side effect. It is important to monitor for this because it can indicate a potentially serious adverse reaction called angioedema. Hyperkalemia (B) is a possible side effect of enalapril but is typically not as urgent to monitor as cough. Hypotension (C) is a common side effect but is usually monitored during the initial dose titration. Dizziness (D) is a less common side effect and is often transient. Monitoring for cough is crucial to detect and manage any potential angioedema promptly.

Correct Answer: C

Rationale: The correct answer is C) Clear lung sounds and decreased heart rate. In heart failure, the heart's inability to pump effectively leads to fluid buildup in the lungs, causing crackles or wheezes on auscultation. Clear lung sounds indicate improved gas exchange and reduced pulmonary congestion, reflecting successful treatment. Decreased heart rate suggests that the heart is functioning more efficiently, reducing the workload on the heart. Option A, weight loss and diuresis, may occur with successful heart failure treatment due to fluid removal, but it does not directly indicate improved cardiac function. Option B, warm skin and less fatigue, are not specific indicators of heart failure treatment success but may be related to general well-being. Option D, absence of chest pain and improved level of consciousness (LOC), are important outcomes but do not directly reflect the effectiveness of heart failure treatment. Educationally, understanding these indicators is crucial for nurses caring for patients with heart failure. Monitoring lung sounds and heart rate helps assess treatment effectiveness, guiding interventions and optimizing patient outcomes. This question reinforces the importance of recognizing key clinical indicators of heart failure improvement.

Correct Answer: D

Rationale: In this scenario, the most important information to communicate to the physician regarding the use of fibrinolytic therapy with tPA for a patient with acute myocardial infarction is option D) The patient has had continuous chest pain since 1:00 PM. The correct answer is D because the duration of chest pain is a critical factor in determining the eligibility for fibrinolytic therapy. The time frame of symptom onset is crucial as fibrinolytic therapy is most effective when administered within a specific window period from the onset of symptoms. Option A is incorrect because a history of alteplase use 8 months ago does not impact the current decision-making process for acute management of AMI. Option B is not directly relevant to the decision to administer fibrinolytic therapy. Option C, T wave inversions on the ECG, while important for diagnosing AMI, are not as time-sensitive as the duration of chest pain in determining the need for immediate fibrinolytic therapy. Educationally, understanding the time-sensitive nature of interventions in acute conditions like AMI is crucial for healthcare providers. Timely communication of critical information to the healthcare team can significantly impact patient outcomes, making it essential for healthcare professionals to prioritize and convey relevant details accurately and promptly.

Correct Answer: C

Rationale: In this scenario, option C, "The patient's vision is becoming 'fuzzy'," is the correct answer that would warrant notifying the physician. This symptom could indicate digoxin toxicity, as visual disturbances are a common sign. It is crucial to address this promptly to prevent serious complications. Option A, "The patient's apical pulse is 68 and very irregular," may be concerning due to the irregularity, but in a patient with atrial fibrillation on digoxin, an irregular pulse is expected. It is not necessarily an immediate cause for concern unless accompanied by other symptoms. Option B, "The patient takes the digoxin with meals," is incorrect as taking digoxin with meals does not raise immediate concerns; however, adherence to dosing instructions should still be reinforced for optimal drug effectiveness. Option D, "The patient has lung crackles that clear after coughing," is unrelated to digoxin therapy and suggests a potential respiratory issue that would require further assessment but is not directly related to the medication. Educationally, this question highlights the importance of recognizing early signs of digoxin toxicity, emphasizing the need for close monitoring of patients on this medication, especially the elderly. It also underscores the significance of assessing for drug-related side effects and differentiating them from unrelated symptoms for appropriate intervention.