A patient who takes warfarin (Coumadin) is brought to the emergency department after accidentally taking too much warfarin. The patient's heart rate is 78 beats per minute and the blood pressure is 120/80 mm Hg. Dipstick urinalysis is normal. The patient does not have any signs of bleeding and does not complain of pain. The nurse will anticipate an order for:

vitamin K (phytonadione)

protamine sulfate

a PTT lab test

an INR lab test

Answer and Explanation

The Correct Answer is A

Choice A reason:
Vitamin K (phytonadione) is the antidote for warfarin overdose. It works by promoting the synthesis of clotting factors that are inhibited by warfarin, thereby reversing the anticoagulant effects. In cases of excessive warfarin intake, administering vitamin K helps restore normal clotting function.

Choice B reason:
Protamine sulfate is the antidote for heparin overdose, not warfarin. It works by neutralizing the anticoagulant effects of heparin, but it has no effect on warfarin-induced anticoagulation. Therefore, it is not appropriate for this situation.

Choice C reason:
A PTT lab test measures the effectiveness of the intrinsic pathway of coagulation and is primarily used to monitor heparin therapy. It is not relevant for managing warfarin overdose, as warfarin affects the extrinsic pathway, which is measured by the PT/INR test.

Choice D reason:
While an INR lab test is essential for monitoring the therapeutic levels of warfarin, the immediate need in this situation is to reverse the effects of the overdose. Administering vitamin K is the necessary intervention to counteract the excessive anticoagulation caused by warfarin.

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Correct Answer is D

Explanation

Choice D reason: The backup of pancreatic enzymes is the initial trigger for tissue damage in pancreatitis. When these enzymes become activated within the pancreas, they begin to digest pancreatic tissue, leading to inflammation and damage.
Choice A reason: Insulin toxicity is not a cause of tissue damage in pancreatitis. Insulin is a hormone that regulates blood sugar levels and does not play a role in the initial damage seen in pancreatitis.
Choice B reason: Autoimmune destruction of the pancreas is associated with conditions like type 1 diabetes, not pancreatitis. Pancreatitis is primarily caused by the premature activation of digestive enzymes within the pancreas.
Choice C reason: Hydrochloric acid reflux into the pancreatic duct is not a known cause of pancreatitis. The condition is related to the digestive enzymes produced by the pancreas itself, not stomach acid.

A. Hold the heparin and notify the provider B. Request an order for vitamin K (phytonadione) C. Request an order for a PTT test D. Administer oxygen and notify the provider

Correct Answer is A

Explanation

Choice A reason:
Holding the heparin and notifying the provider is the appropriate action. The significant drop in platelet count suggests the possibility of heparin-induced thrombocytopenia (HIT), a serious complication of heparin therapy. Immediate discontinuation of heparin and further evaluation are necessary to manage this condition.

Choice B reason:
Requesting an order for vitamin K (phytonadione) is not appropriate in this scenario. Vitamin K is used to reverse the effects of warfarin, not heparin. The issue here is the potential for HIT, not an over-anticoagulation that requires vitamin K.

Choice C reason:
While requesting a PTT test is part of managing anticoagulation therapy, it is not the immediate priority in this case. The significant drop in platelet count is more concerning for HIT, which requires stopping heparin and notifying the provider for further evaluation.

Choice D reason:
Administering oxygen and notifying the provider is not specific to managing the issue of a significantly low platelet count in a patient on heparin. The primary concern here is the potential for HIT, which necessitates stopping the heparin.

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Naxlex Comprehensive Predictor Exams

Tissue damage in pancreatitis is initially triggered by:

Correct Answer is D

Explanation

A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 110 beats per minute and a blood pressure of 90/62 mm Hg. A stat CBC shows a platelet count of less than 50,000, which is a low platelet count. The previous platelet level was 375,000. The nurse will:

Correct Answer is A

Explanation

Sucralfate reduces acid production in the stomach. A nursing student is caring for a patient who is taking sucralfate (Carafate) to treat peptic ulcer disease. The student asks the nurse about the pharmacokinetics of sucralfate. Which statement by the student indicates a need for further teaching?

A postoperative patient reports a new pain in the left lower extremity. The nurse notes swelling in the lower leg, which feels warm to the touch. The nurse notifies the MD of the patient's change in condition. Which medication will the RN anticipate giving?

Cardiac cells can withstand ischemic conditions for 20 minutes before irreversible cell injury occurs:

The nurse is providing education to a patient who has been prescribed both an antacid and ranitidine (an H2 receptor blocker). Which instruction should the nurse give the patient about taking the medications?

A nurse reads in a drug information guide that PO (oral) morphine has a high first-pass effect. Which of the following statements would demonstrate the nurse's understanding of the first-pass effect?

A nursing student who is preparing to care for a postoperative patient with deep vein thrombosis asks the nurse why the patient must take heparin rather than warfarin. Which response by the nurse is correct?