A nurse is caring for a client who is receiving warfarin therapy to prevent deep vein thrombosis. Which of the following medications should the nurse have available in the event of an overdose?

Epinephrine

Vitamin K

Atropine

Protamine

Answer and Explanation

The Correct Answer is B

Choice A reason : Epinephrine is an adrenergic agonist primarily used in the management of cardiac arrest, anaphylaxis, and severe asthma attacks. It is not used to reverse the effects of warfarin overdose. Warfarin acts as an anticoagulant by inhibiting vitamin K-dependent clotting factors, and epinephrine has no role in this mechanism.

Choice B reason : Vitamin K is the antidote for warfarin toxicity. Warfarin works by inhibiting the vitamin K-dependent clotting factors II, VII, IX, and X. In the event of an overdose, vitamin K is administered to reverse the anticoagulant effects of warfarin and restore the clotting factor levels to normal. The administration can be oral or intravenous, depending on the severity of the overdose and the urgency of the situation.

Choice C reason : Atropine is an anticholinergic drug used to treat bradycardia (slow heart rate) and as an antidote for organophosphate poisoning. It does not have a role in reversing warfarin overdose as it does not affect the clotting cascade or vitamin K metabolism.

Choice D reason : Protamine is used to reverse the effects of heparin, another anticoagulant, but not warfarin. Protamine sulfate binds to heparin, forming a stable complex and neutralizing its anticoagulant effects. Since warfarin's mechanism of action is different from heparin's, protamine is not effective in reversing warfarin toxicity.

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Correct Answer is C

Explanation

Choice A reason : A fixed volume deficit, or hypovolemia, is not a direct finding associated with bradycardia. Bradycardia refers to a slower than normal heart rate, typically below 60 beats per minute in adults⁸. Hypovolemia can cause various compensatory mechanisms to activate, including an increase in heart rate to maintain cardiac output, which is the opposite of bradycardia. Therefore, a fixed volume deficit is not a typical finding in bradycardia unless it is part of a broader clinical picture⁹.

Choice B reason : Anxiety is a condition that can sometimes lead to an increased heart rate, known as tachycardia, rather than a decreased heart rate as seen in bradycardia. While anxiety can coexist with bradycardia, especially if the patient is anxious about their health, it is not a direct symptom or finding of bradycardia itself⁹.

Choice C reason : Lightheadedness is a common symptom of bradycardia. When the heart rate is too slow, it may lead to inadequate cerebral perfusion, which can cause a feeling of lightheadedness or dizziness. This symptom can be particularly evident when the patient changes positions, such as standing up quickly, which can exacerbate the effects of reduced cardiac output on cerebral blood flow⁸⁹.

Choice D reason : An elevated temperature is not typically associated with bradycardia. Fever can actually lead to an increased heart rate as the body attempts to manage the higher metabolic demands associated with a raised temperature. Bradycardia in the presence of fever might indicate a more complex clinical scenario, such as myocarditis or central nervous system infections, but it is not a direct finding of bradycardia⁹.

A. Check the level of the client's pain. B. Check the client's blood pressure. C. Check the client's bowel sounds. D. Check the client's catheter insertion site.

Correct Answer is A

Explanation

Choice A reason: Pain assessment is a critical priority for postoperative patients. After aortic valve replacement surgery, patients may experience discomfort or pain related to the incision site, chest tube placement, or other surgical interventions. Pain assessment allows the nurse to evaluate the effectiveness of pain management strategies, adjust medications as needed, and ensure the patient's comfort and well-being. Pain can also impact vital signs and overall recovery, so addressing it promptly is essential.

Choice B reason: Monitoring blood pressure is important, but it is not the highest priority immediately after surgery. Blood pressure assessment is part of routine postoperative care, but it does not directly address the patient's immediate comfort or potential complications. However, if the patient's blood pressure becomes significantly abnormal, it would require immediate attention.

Choice C reason: Checking bowel sounds is relevant for assessing gastrointestinal function, but it is not the top priority immediately postoperatively. Bowel sounds may be diminished initially due to anesthesia, surgical manipulation, or bowel rest. However, assessing pain and other vital signs takes precedence over bowel sounds in the immediate recovery period.

Choice D reason: Assessing the catheter insertion site is essential, especially if the patient has an indwelling urinary catheter. However, it is not the highest priority immediately after aortic valve replacement. Pain assessment and monitoring for complications related to surgery (such as bleeding, infection, or cardiac issues) take precedence. The catheter site can be assessed during routine nursing care.

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A nurse is caring for a client who is receiving warfarin therapy to prevent deep vein thrombosis. Which of the following medications should the nurse have available in the event of an overdose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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