A nurse is caring for a client who is receiving warfarin therapy to prevent deep vein thrombosis. Which of the following medications should the nurse have available in the event of an overdose?
Epinephrine
Vitamin K
Atropine
Protamine
The Correct Answer is B
Choice A reason : Epinephrine is an adrenergic agonist primarily used in the management of cardiac arrest, anaphylaxis, and severe asthma attacks. It is not used to reverse the effects of warfarin overdose. Warfarin acts as an anticoagulant by inhibiting vitamin K-dependent clotting factors, and epinephrine has no role in this mechanism.
Choice B reason : Vitamin K is the antidote for warfarin toxicity. Warfarin works by inhibiting the vitamin K-dependent clotting factors II, VII, IX, and X. In the event of an overdose, vitamin K is administered to reverse the anticoagulant effects of warfarin and restore the clotting factor levels to normal. The administration can be oral or intravenous, depending on the severity of the overdose and the urgency of the situation.
Choice C reason : Atropine is an anticholinergic drug used to treat bradycardia (slow heart rate) and as an antidote for organophosphate poisoning. It does not have a role in reversing warfarin overdose as it does not affect the clotting cascade or vitamin K metabolism.
Choice D reason : Protamine is used to reverse the effects of heparin, another anticoagulant, but not warfarin. Protamine sulfate binds to heparin, forming a stable complex and neutralizing its anticoagulant effects. Since warfarin's mechanism of action is different from heparin's, protamine is not effective in reversing warfarin toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Pain assessment is a critical priority for postoperative patients. After aortic valve replacement surgery, patients may experience discomfort or pain related to the incision site, chest tube placement, or other surgical interventions. Pain assessment allows the nurse to evaluate the effectiveness of pain management strategies, adjust medications as needed, and ensure the patient's comfort and well-being. Pain can also impact vital signs and overall recovery, so addressing it promptly is essential.
Choice B reason: Monitoring blood pressure is important, but it is not the highest priority immediately after surgery. Blood pressure assessment is part of routine postoperative care, but it does not directly address the patient's immediate comfort or potential complications. However, if the patient's blood pressure becomes significantly abnormal, it would require immediate attention.
Choice C reason: Checking bowel sounds is relevant for assessing gastrointestinal function, but it is not the top priority immediately postoperatively. Bowel sounds may be diminished initially due to anesthesia, surgical manipulation, or bowel rest. However, assessing pain and other vital signs takes precedence over bowel sounds in the immediate recovery period.
Choice D reason: Assessing the catheter insertion site is essential, especially if the patient has an indwelling urinary catheter. However, it is not the highest priority immediately after aortic valve replacement. Pain assessment and monitoring for complications related to surgery (such as bleeding, infection, or cardiac issues) take precedence. The catheter site can be assessed during routine nursing care.
Correct Answer is B
Explanation
Choice A reason : An erythrocyte sedimentation rate (ESR) test is not directly related to high serum potassium levels and would not be the immediate action in response to hyperkalemia.
Choice B reason : Obtaining a 12-lead ECG is a critical step when hyperkalemia is suspected because high potassium levels can cause life-threatening cardiac arrhythmias. An ECG can quickly reveal characteristic changes associated with hyperkalemia, allowing for prompt treatment.
Choice C reason : Administering potassium gluconate would be contraindicated in a patient with hyperkalemia, as it would further increase the serum potassium levels, potentially leading to severe complications.
Choice D reason : Restricting fluid intake is not a standard treatment for hyperkalemia. The management of hyperkalemia may include medications or procedures that promote the excretion of potassium or move potassium from the blood into the cells.
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