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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : Regular exercise, as tolerated and recommended by a healthcare provider, is beneficial for heart failure patients as it can improve cardiovascular health and overall well-being⁵.
Choice B reason : Taking naproxen sodium for generalized discomfort is not recommended for heart failure patients as nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen heart failure by causing fluid retention and increasing blood pressure⁵.
Choice C reason : Taking diuretics early in the morning is advised to avoid nocturia; however, taking them before bedtime is not recommended for the same reason, as it can disrupt sleep due to the need for frequent urination⁵.
Choice D reason : Patients should be instructed to notify their healthcare provider of a weight gain of 0.5 kg (1 lb) in a week as it may indicate fluid retention, which is a common issue in heart failure⁵.
Correct Answer is A
Explanation
Choice A reason : Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, which can cause blood vessels to expand, leading to headaches. Patients should be informed that this is a common reaction and can be managed with over-the-counter pain relievers if necessary¹²³⁴.
Choice B reason : A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions would more likely present with symptoms such as rash, itching, or difficulty breathing.
Choice C reason : While anxiety can cause headaches, in this context, the headache is more likely a direct side effect of the nitroglycerin, especially since it occurred after taking the medication and the chest pain was relieved.
Choice D reason : Tolerance to medication refers to a reduced response to a drug over time, requiring higher doses to achieve the same effect. A headache after taking nitroglycerin does not indicate tolerance; it is a known side effect of the drug.
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