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 D
Explanation
Choice A reason: Monitoring daily weight can help detect early signs of lithium toxicity, as sudden weight gain may indicate fluid retention, which is a concern with lithium treatment. It is important for clients to monitor their weight regularly to ensure no significant fluctuations occur that could suggest adverse effects⁴.
Choice B reason: Avoiding foods with high tyramine content is not specifically related to lithium therapy. This dietary restriction is more commonly associated with monoamine oxidase inhibitors (MAOIs), a different class of psychiatric medications. Lithium does not interact with tyramine in the same way⁴.
Choice C reason: Limiting daily fluid intake is not recommended for clients taking lithium unless otherwise directed by a healthcare provider. Adequate fluid intake is essential to prevent dehydration, which can increase lithium levels and the risk of toxicity. Clients should maintain a consistent intake of fluids unless they have a condition that requires fluid restriction⁴⁵.
Choice D reason: Following a low sodium diet is not advised for clients on lithium therapy. Lithium is processed in the body similarly to sodium, so if sodium levels are too low, lithium retention may increase, leading to toxicity. Clients should maintain a consistent, adequate intake of sodium to prevent fluctuations in lithium levels⁴.
Correct Answer is D
Explanation
Choice A reason : Cleaning dentures in a denture cup is a standard hygiene practice but does not directly address the low WBC count. While maintaining oral hygiene is important, it is not the most critical action related to the client's immunocompromised state⁶.
Choice B reason : Replacing the water in flower vases daily is a good practice to prevent bacterial growth; however, it is recommended to avoid having flowers or plants in the room of an immunocompromised patient due to the risk of exposure to fungi and bacteria⁷.
Choice C reason : Humidifying the room can be beneficial for respiratory comfort, but it must be done with caution in immunocompromised patients. Humidifiers need to be kept clean to prevent the growth of bacteria and fungi, which could be harmful to a patient with a low WBC count⁷.
Choice D reason : Serving cooked fruit with meals is the correct action because cooking fruit can eliminate potential pathogens that the client's compromised immune system may not be able to handle. Raw fruits and vegetables can harbor bacteria and other pathogens, so serving them cooked is a safer option for someone with a low WBC count⁶⁷.
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