A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication?

The antidote for warfarin is protamine.

The client should be observed for manifestations of hemorrhage.

The client's aPTT should be monitored.

Warfarin can be administered along with NSAIDs.

Answer and Explanation

The Correct Answer is B

Choice A reason: The statement that the antidote for warfarin is protamine is incorrect. The primary antidote for warfarin is Vitamin K, and in cases of significant bleeding, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be used¹². Protamine is used as an antidote for heparin, not warfarin¹.

Choice B reason: Observing the client for manifestations of hemorrhage is a critical nursing action when administering warfarin. Warfarin is an anticoagulant, and one of the major risks associated with its use is bleeding. The nurse should monitor for signs such as unusual bruising, petechiae, hematuria, tarry stools, or any other indications of internal or external bleeding⁷⁸.

Choice C reason: Monitoring the client's aPTT (activated partial thromboplastin time) is not typically associated with warfarin therapy. Warfarin's effect is monitored through the prothrombin time (PT) and the International Normalized Ratio (INR), not aPTT, which is more commonly used to monitor heparin therapy⁴⁵.

Choice D reason: Warfarin should not be administered along with NSAIDs without careful consideration and monitoring due to the increased risk of bleeding. NSAIDs can affect platelet function and gastrointestinal mucosa, leading to an elevated risk of gastrointestinal bleeding when taken with warfarin¹¹¹².

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason : Constipation is not commonly reported as an adverse effect of tamoxifen. While it may occur, it is not as prevalent as other side effects such as hot flashes¹.

Choice B reason : Hot flashes are a well-known and common adverse effect of tamoxifen. They occur due to the antiestrogen effects of the medication, which can disrupt the body's temperature regulation¹.

Choice C reason : Increased appetite is not typically associated with tamoxifen use. While changes in weight can occur, they are not directly linked to an increase in appetite as a side effect of this medication¹.

Choice D reason : Insomnia may occur in some individuals taking tamoxifen, but it is not one of the most common adverse effects. Hot flashes and other menopausal-like symptoms are more frequently reported¹.

A. Encourage avoidance of situations that increase anxiety. B. Investigate what situations precipitate anxiety. C. Teach the client that compulsive behavior is excessive. D. Prevent the client from performing compulsive behavior.

Correct Answer is B

Explanation

Choice A reason : Encouraging avoidance of anxiety-increasing situations may seem beneficial, but it can reinforce OCD behaviors. Avoidance prevents the client from learning how to cope with anxiety and can limit their ability to participate in daily activities⁴.

Choice B reason : Investigating what situations precipitate anxiety is a crucial step in managing OCD. Understanding the specific triggers can help in developing strategies to cope with and eventually reduce the anxiety associated with these situations. This approach is aligned with cognitive-behavioral therapy principles, which are effective in treating OCD⁴⁵.

Choice C reason : Teaching the client that compulsive behavior is excessive is part of psychoeducation. However, simply telling a client that their behavior is excessive without providing coping mechanisms can be unhelpful and may increase their anxiety. It's important to combine this with therapeutic techniques that help the client manage their compulsions⁴.

Choice D reason : Preventing the client from performing compulsive behavior abruptly can cause significant distress and may not be feasible or safe. Instead, treatment usually involves gradual exposure to anxiety-provoking situations and learning to resist the urge to perform compulsions, a technique known as exposure and response prevention (ERP)⁴.

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A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for tamoxifen to treat breast cancer. The nurse should include that which of the following is an adverse effect of this medication?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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