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 C

Explanation

Choice A reason : Bubbling in the water seal chamber with exhalation can be a normal finding as it indicates that air is being evacuated from the pleural space. However, continuous bubbling may suggest an air leak, which should be evaluated.

Choice B reason : The visibility of the eyelets is not typically a concern unless the tube is dislodged. If the chest tube is functioning properly and the eyelets are meant to be within the chest cavity, their visibility might indicate dislodgement.

Choice C reason : Crepitus, or subcutaneous emphysema, can occur if air leaks into the tissue surrounding the insertion site. This can be a sign of a problem with the chest tube placement or function and should be reported to the provider immediately.

Choice D reason : Movement of the trachea toward the unaffected side, or tracheal deviation, can be a sign of tension pneumothorax, a life-threatening condition that requires immediate attention.

A. Tongue thrusting and lip smacking B. Fine hand tremors and pill rolling C. Urinary retention and constipation D. Loud talking and pacing

Correct Answer is A

Explanation

Choice A reason : Tongue thrusting and lip smacking are classic signs of tardive dyskinesia (TD), a side effect of long-term use of dopamine receptor-blocking agents like haloperidol¹. TD is characterized by repetitive, involuntary, purposeless movements, primarily affecting the facial, mouth, and tongue muscles².

Choice B reason : Fine hand tremors and pill rolling are more commonly associated with Parkinson's disease, which is a different type of movement disorder. While antipsychotic medications can cause extrapyramidal symptoms that resemble Parkinson's disease, these are not indicative of tardive dyskinesia².

Choice C reason : Urinary retention and constipation can be side effects of antipsychotic medications due to their anticholinergic effects. However, these are not symptoms of tardive dyskinesia, which specifically involves involuntary movements².

Choice D reason : Loud talking and pacing may be related to the underlying condition of acute psychosis or could be a behavioral side effect of antipsychotic medication, but they are not symptoms of tardive dyskinesia².

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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 assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol (Haldol). The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following?

Correct Answer is A

Explanation

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