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 B
Explanation
Choice A reason : A hemoglobin (Hgb) level of 16 g/dL is within the normal range for adults, which typically falls between 13.8 to 17.2 g/dL for men and 12.1 to 15.1 g/dL for women. Therefore, this value does not warrant reporting to the provider as it does not indicate an immediate concern.
Choice B reason : A prothrombin time (PT) of 45 seconds is significantly higher than the normal range of 11 to 13.5 seconds for individuals not on anticoagulation therapy. For patients on warfarin, the target PT is usually 1.5 to 2 times the normal value, depending on the indication for therapy. However, a PT of 45 seconds suggests a high risk of bleeding and requires immediate medical attention.
Choice C reason : The activated partial thromboplastin time (aPTT) of 36 seconds is within the normal range of approximately 21 to 35 seconds⁸. This result indicates that the blood's intrinsic clotting pathway is functioning within expected parameters and does not need to be reported.
Choice D reason : A platelet count of 190,000/mm is within the normal range, which is typically 150,000 to 450,000 platelets/mm. This value is not concerning and does not need to be reported to the provider.
Correct Answer is D
Explanation
Choice A reason : Assisting the client into a standing position is part of the process for checking orthostatic hypotension, but it is not the first action to take. The initial measurement should be taken while the client is supine to establish a baseline blood pressure before any position changes.
Choice B reason : Determining the client's blood pressure 1 minute after each position change is important for diagnosing orthostatic hypotension, but it follows after the initial supine measurement. This step is to observe changes in blood pressure that may indicate orthostatic hypotension.
Choice C reason : Placing the client in a sitting position is another step in the process of checking for orthostatic hypotension. However, it is not the first action. The nurse should first measure the blood pressure in the supine position, then sitting, and finally standing.
Choice D reason : This is the correct first action. Checking the client's blood pressure in a supine position provides a baseline measurement. After this, the nurse can compare the blood pressure readings after the client sits and stands to identify any significant drops that would indicate orthostatic hypotension.
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