A nurse is caring for a client who is experiencing warfarin toxicity. Which of the following medications should the nurse administer?
Protamine sulfate
Vitamin K
Calcium gluconate
Acetylcysteine
The Correct Answer is B
A. Protamine sulfate: Protamine sulfate is used to reverse the effects of heparin, not warfarin. Administering it in warfarin toxicity would not effectively counteract the anticoagulant effect and could delay appropriate treatment.
B. Vitamin K: Vitamin K is the antidote for warfarin toxicity. It promotes synthesis of clotting factors II, VII, IX, and X, which are inhibited by warfarin, helping to restore normal coagulation and reduce the risk of bleeding.
C. Calcium gluconate: Calcium gluconate is primarily used to treat hypocalcemia or cardiac effects of hyperkalemia. It does not reverse warfarin-induced anticoagulation and would not address the underlying risk of bleeding.
D. Acetylcysteine: Acetylcysteine is an antidote for acetaminophen toxicity and works by replenishing glutathione. It has no effect on warfarin metabolism or clotting factor synthesis, making it inappropriate for this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is "{\"xRanges\":[26.598316618911177,38.05963467048711],\"yRanges\":[63.14199395770393,75.22658610271904]}"
Explanation
A. Right upper quadrant of the abdomen: An open cholecystectomy involves surgical removal of the gallbladder, which is located in the right upper quadrant beneath the liver. The incision is typically made just below the right rib cage, making area A the correct site for the dressing change.
B. Midline of the upper abdomen: This area corresponds to the epigastric region and would not align with the typical location for a gallbladder incision. Incisions here are more common for other abdominal surgeries, such as exploratory laparotomy.
C. Lower midline abdomen: This area is associated with procedures involving the lower gastrointestinal tract, such as appendectomy or hysterectomy, and is not consistent with a cholecystectomy incision.
D. Right lower quadrant: This region is typically related to surgeries involving the appendix, cecum, or right ovary, not the gallbladder. Selecting this area would not correspond to the correct postoperative site for a cholecystectomy.
Correct Answer is D
Explanation
A. Visual Analog Scale: The visual analog scale requires the child to understand and mark a point on a line representing pain intensity. This scale is appropriate for older children, usually around 7 years and older, and not for an 8-month-old infant.
B. FACES pain scale: The FACES scale uses facial expressions to help children identify pain intensity, but it is suitable for children aged 3 years and older who can understand the concept of choosing a face to represent their pain.
C. Oucher scale: The Oucher scale also relies on the child’s ability to self-report pain by selecting a photograph or numerical representation. It is not appropriate for infants who cannot communicate their pain cognitively.
D. FLACC scale: The FLACC scale assesses pain in infants and young children by observing five criteria: Face, Legs, Activity, Cry, and Consolability. It allows the nurse to evaluate pain objectively in an 8-month-old who cannot verbally self-report.
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