A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

Heparin

Vitamin K

Iron

Protamine

Answer and Explanation

The Correct Answer is B

Choice A reason:

Administering Heparin to a patient who is already taking Warfarin and experiencing rectal bleeding is not appropriate. Heparin is an anticoagulant, similar to Warfarin, and would not help in reversing the anticoagulant effects of Warfarin. Instead, it could potentially exacerbate the bleeding.

Choice B reason:

Vitamin K is the correct answer because it acts as an antidote to Warfarin. Warfarin works by inhibiting the synthesis of Vitamin K-dependent clotting factors, so administering Vitamin K helps to reverse the effects of Warfarin and promote blood clotting, which is necessary to control the rectal bleeding in this patient.

Choice C reason:

Iron is not the appropriate treatment for rectal bleeding due to Warfarin. While iron supplements can help with anemia (which might result from chronic blood loss), they do not address the immediate need to reverse the anticoagulant effects of Warfarin and stop the active bleeding.

Choice D reason:

Protamine is used to reverse the effects of Heparin, not Warfarin. Therefore, administering Protamine would not be effective in addressing the Warfarin-induced rectal bleeding in this patient.

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Correct Answer is D

Explanation

Choice A reason:

Encouraging the patient to deep breathe and use an incentive spirometer is important for lung expansion and preventing atelectasis. However, it is not the most immediate action following extubation.

Choice B reason:

Offering the patient medication for sedation is not appropriate immediately following extubation, as it could depress respiratory function and interfere with the patient's ability to clear secretions and maintain an open airway.

Choice C reason:

Assessing the patient's ability to speak is important to ensure that the vocal cords were not damaged during the intubation process. However, this is secondary to ensuring that the patient is breathing effectively and maintaining adequate oxygenation.

Choice D reason:

Assessing vital signs and effort of breathing is the most immediate and important action following extubation. Monitoring the patient’s respiratory status ensures that they are maintaining a patent airway, breathing effectively, and not experiencing respiratory distress or failure.

A. Elevate the client's head on two pillows B. Decrease the noise level in the client's room C. Suction the endotracheal tube frequently D. Administer a stool softener E. Give a 500cc NS fluid bolus

Correct Answer is ["B","D","E"]

Explanation

Choice A reason:

Elevating the client's head on two pillows is not a standardized method for managing intracranial pressure. Instead, elevating the head of the bed to 30 degrees is a more effective strategy to promote venous drainage and reduce ICP.

Choice B reason:

Decreasing the noise level in the client's room helps create a calm environment, which can reduce stress and prevent increases in ICP. Excessive noise and stimulation can elevate intracranial pressure.

Choice C reason:

Frequent suctioning of the endotracheal tube can actually increase ICP due to the stimulation and potential for causing a cough reflex. Suctioning should be performed only as necessary and with care.

Choice D reason:

Administering a stool softener helps prevent straining during bowel movements, which can increase ICP. Ensuring regular and comfortable bowel movements is crucial in managing intracranial pressure.

Choice E reason:

Giving a 500cc NS fluid bolus can be appropriate in some clinical scenarios to maintain adequate blood pressure and perfusion. However, fluid management must be carefully balanced to avoid fluid overload, which could increase ICP. Generally, fluid boluses are not the primary method for managing ICP.

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A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which would be the most important action immediately following extubation of a patient?

Correct Answer is D

Explanation

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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