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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason : Documenting the frequency of blood pressure measurements is crucial for monitoring trends and identifying any changes that may indicate a health issue. It helps in assessing the effectiveness of interventions and in making informed clinical decisions.
Choice B reason : Recording the interventions implemented in response to a high blood pressure reading is important for continuity of care. It ensures that all healthcare providers are aware of the actions taken and can evaluate their effectiveness.
Choice C reason : Noting the patient's response to interventions provides insight into the efficacy of the treatment plan. It is essential for adjusting care plans and for healthcare providers to understand the patient's progress.
Choice D reason : Identifying the person who obtained the blood pressure reading is a part of proper documentation practices. It allows for accountability and follow-up if there are any questions or concerns about the reading.
Choice E reason : The site where the blood pressure was taken can affect the reading. Documenting this information helps to ensure that readings are consistent and comparable over time. It is also important in case an alternative site needs to be used in future measurements.
Correct Answer is D
Explanation
Choice A reason : Assisting the client into a standing position is part of the process for checking orthostatic hypotension, but it is not the first action to take. The initial measurement should be taken while the client is supine to establish a baseline blood pressure before any position changes.
Choice B reason : Determining the client's blood pressure 1 minute after each position change is important for diagnosing orthostatic hypotension, but it follows after the initial supine measurement. This step is to observe changes in blood pressure that may indicate orthostatic hypotension.
Choice C reason : Placing the client in a sitting position is another step in the process of checking for orthostatic hypotension. However, it is not the first action. The nurse should first measure the blood pressure in the supine position, then sitting, and finally standing.
Choice D reason : This is the correct first action. Checking the client's blood pressure in a supine position provides a baseline measurement. After this, the nurse can compare the blood pressure readings after the client sits and stands to identify any significant drops that would indicate orthostatic hypotension.
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