A nurse is collecting data from a client who is taking warfarin and has an elevated PT/INR. Which of the following medications should the nurse anticipate administering?

Vitamin K

Naloxone

Disulfiram

Protamine

Answer and Explanation

The Correct Answer is A

A. Vitamin K is the antidote for excessive anticoagulation caused by warfarin. It helps to reverse the effects of warfarin by promoting the synthesis of clotting factors.

B. Naloxone is used to reverse opioid overdose, not related to warfarin or its effects.

C. Disulfiram is used to treat alcohol use disorder by causing unpleasant effects when alcohol is consumed, and is unrelated to warfarin.

D. Protamine is used to reverse the effects of heparin, not warfarin.

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Correct Answer is B

Explanation

A. The ECG finding of an irregularly irregular heart rate without P waves is characteristic of atrial fibrillation, which is expected in this client. This finding is not the priority in this situation.

B. Slurred speech is a potential sign of a stroke, which is a serious complication of atrial fibrillation due to the increased risk of thromboembolic events (e.g., stroke). This is the priority finding because it requires immediate intervention to assess and manage a possible stroke.

C. An aPTT of 70 seconds is slightly elevated, but it is within the therapeutic range for heparin therapy (usually 1.5 to 2.5 times the normal value). It does not warrant immediate action.

D. Cloudy and odorous urine could indicate a urinary tract infection or other issue, but it is not immediately life-threatening compared to the potential for a stroke in this client.

A. It must be hard to see your mother so ill and upset. B. If you just sit quietly with your mother, I'm sure she will calm down. C. I'll talk with your mother and see if I can comfort her. D. "Your mother's crying seems to bother you more than it does her."

Correct Answer is A

Explanation

A. It must be hard to see your mother so ill and upset is a compassionate and empathetic response that acknowledges the son's distress while validating his feelings. This approach fosters open communication and emotional support, which is important for both the patient and their family.

B. Telling the son to sit quietly with his mother may invalidate his feelings and suggests that the solution is simply to wait for the mother to calm down. It does not acknowledge his emotional distress or provide the necessary support.

C. While offering to comfort the mother is kind, this response does not address the son’s emotional needs. It is important to support the family members as well, not just the patient.

D. "Your mother's crying seems to bother you more than it does her" is dismissive of the son's feelings and could make him feel misunderstood or judged. It does not provide the necessary emotional support for the son.

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A nurse is collecting data from a client who is taking warfarin and has an elevated PT/INR. Which of the following medications should the nurse anticipate administering?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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