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

Correct Answer: A

Rationale: The correct answer is A: Administer vitamin K as an antidote. An INR of 5.5 indicates the client is at risk for bleeding due to excessive anticoagulation from warfarin. Administering vitamin K helps reverse the effects of warfarin and lowers the INR back to the therapeutic range. Holding the next dose of warfarin (B) is important but not the priority over administering the antidote. Increasing the dose of warfarin (C) would worsen the situation. Administering fresh frozen plasma (D) is not a standard treatment for high INR levels due to warfarin.

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. Consuming foods high in potassium while on spironolactone can lead to hyperkalemia, which is an elevated level of potassium in the blood. This can result in serious health complications such as irregular heartbeats and muscle weakness. Therefore, it is crucial for clients on spironolactone to avoid foods high in potassium to prevent these adverse effects. Choices B, C, and D are incorrect because spironolactone does not specifically interact with sodium, calcium, or chloride in a way that necessitates avoiding foods high in these electrolytes.

Correct Answer: A

Rationale: The correct answer is A: Platelet count. Enoxaparin is an anticoagulant that works by preventing blood clots. Monitoring platelet count is crucial to assess for potential thrombocytopenia, a side effect of enoxaparin that can increase the risk of bleeding. Hemoglobin (B) and White blood cell count (C) are not directly affected by enoxaparin. aPTT (D) is not the most important lab value to monitor as enoxaparin does not directly affect this clotting parameter.

Correct Answer: D

Rationale: The correct answer is D: Decreases blood pressure. Calcium channel blockers inhibit the influx of calcium into cardiac and smooth muscle cells, leading to vasodilation and decreased peripheral resistance, ultimately reducing blood pressure. This effect is beneficial in conditions such as hypertension and angina. The other choices are incorrect because calcium channel blockers typically do not directly affect heart rate or increase blood pressure.

Correct Answer: A

Rationale: The correct answer is A: Platelet count. Enoxaparin is a low molecular weight heparin that can cause thrombocytopenia, a potentially serious side effect. Monitoring platelet count is crucial to detect any decrease, as it may increase the risk of bleeding. PT/INR and aPTT are used to monitor warfarin and heparin, respectively, not enoxaparin. Hemoglobin monitoring is important for anemia but not the most crucial lab value in this scenario.