A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?
Warfarin
Vitamin K
Heparin
Ferrous sulfate
The Correct Answer is B
A. Warfarin:
Warfarin is an anticoagulant that works by inhibiting the synthesis of certain clotting factors, including factors II, VII, IX, and X. While it is used to prevent thromboembolic events, in a client with cirrhosis and an elevated PT, the priority is addressing the coagulation factor deficiency rather than adding an anticoagulant.
B. Vitamin K:
Vitamin K is the antidote for warfarin, and it helps in the synthesis of clotting factors. In cirrhosis, there can be impaired synthesis of clotting factors due to liver dysfunction. Administering vitamin K can aid in correcting coagulation abnormalities.
C. Heparin:
Heparin is another anticoagulant, but it does not reverse the effects of warfarin. It works by a different mechanism and is typically used in acute settings, such as deep vein thrombosis or pulmonary embolism. It is not the primary intervention for an elevated PT in cirrhosis.
D. Ferrous sulfate:
Ferrous sulfate is an iron supplement and is not indicated for the correction of an elevated PT. Iron supplements are typically used to address iron deficiency anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Wear compression stockings daily":
Compression stockings are not directly related to preventing the complications of retinopathy and nephropathy in diabetes. They are more commonly recommended for managing conditions like venous insufficiency and preventing blood clots.
B. "Have an eye examination once per year":
While regular eye examinations are important for monitoring and early detection of diabetic retinopathy, maintaining stable blood glucose levels is more directly related to preventing the progression of retinopathy.
C. "Maintain stable blood glucose levels":
This is the correct instruction. Stable blood glucose levels are crucial in preventing and minimizing the long-term complications of diabetes, including retinopathy (damage to the retina) and nephropathy (kidney damage). Consistent blood glucose control is key to reducing the risk of complications.
D. "Examine your feet carefully every day":
Daily foot examinations are essential for preventing diabetic foot complications, including ulcers and infections. While important for overall diabetes management, foot care is not specifically directed at preventing retinopathy and nephropathy.
Correct Answer is C
Explanation
A. Clean the peristomal skin four times a day:
While keeping the peristomal skin clean is essential, cleaning it four times a day might be excessive and could lead to skin irritation. Typically, cleansing the area when changing the pouch or as needed is sufficient.
B. Hold pressure on the skin barrier for 10 to 15 seconds to secure the seal:
Applying gentle pressure upon application can assist in securing the seal, but the duration might vary based on the manufacturer's recommendations. It's important not to overly press or manipulate the barrier excessively, as it could cause skin trauma.
C. Empty the pouch when it is 1/3 full:
This is the correct advice. Regularly emptying the pouch prevents leakage and ensures the pouch does not become too heavy or cause skin irritation from weight or pressure.
D. Expect firm fecal content:
With an ileostomy, the fecal content tends to be more liquid compared to other types of ostomies like colostomies, so expecting firm fecal content might not be accurate for this situation.
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