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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Correct Answer is A

Explanation

Choice A reason : In primary hypothyroidism, the thyroid gland is underactive and does not produce sufficient thyroid hormones. As a result, the pituitary gland releases more TSH to stimulate the thyroid, leading to elevated levels of TSH in the blood⁶⁷⁸.

Choice B reason : Free T3 levels might not be elevated in primary hypothyroidism. Free T3 is the active form of triiodothyronine and could be normal or low depending on the severity and type of hypothyroidism⁶.

Choice C reason : Serum T3 levels are typically not the first indicator to change in primary hypothyroidism and may remain within normal ranges even when TSH is elevated⁶.

Choice D reason : Serum T4 levels are expected to be low in primary hypothyroidism because the thyroid gland is not producing enough of this hormone. However, the initial and most sensitive indicator of primary hypothyroidism is an elevated TSH level⁶.

A. Assess risk for immediate harm. B. Refer the client to a community support group. C. Implement a safety plan. D. Instruct the client on how to leave the relationship.

Correct Answer is A

Explanation

Choice A reason : The immediate safety of the client is the nurse's primary concern. Assessing the risk for immediate harm is crucial to prevent further abuse and to ensure the client's well-being. This involves evaluating the severity of the situation and the potential for future harm¹.

Choice B reason : While referring the client to a community support group is important for long-term support, it is not the immediate priority when a client reports abuse.

Choice C reason : Implementing a safety plan is a critical step, but it follows the initial assessment of immediate risk. The safety plan will be part of the ongoing support and intervention for the client.

Choice D reason : Instructing the client on how to leave the relationship is an important aspect of empowering the client; however, it is not the first action to take before assessing immediate risk and ensuring the client's safety.

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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 in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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