A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication?
The antidote for warfarin is protamine.
The client should be observed for manifestations of hemorrhage.
The client's aPTT should be monitored.
Warfarin can be administered along with NSAIDs.
The Correct Answer is B
Choice A reason: The statement that the antidote for warfarin is protamine is incorrect. The primary antidote for warfarin is Vitamin K, and in cases of significant bleeding, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be used¹². Protamine is used as an antidote for heparin, not warfarin¹.
Choice B reason: Observing the client for manifestations of hemorrhage is a critical nursing action when administering warfarin. Warfarin is an anticoagulant, and one of the major risks associated with its use is bleeding. The nurse should monitor for signs such as unusual bruising, petechiae, hematuria, tarry stools, or any other indications of internal or external bleeding⁷⁸.
Choice C reason: Monitoring the client's aPTT (activated partial thromboplastin time) is not typically associated with warfarin therapy. Warfarin's effect is monitored through the prothrombin time (PT) and the International Normalized Ratio (INR), not aPTT, which is more commonly used to monitor heparin therapy⁴⁵.
Choice D reason: Warfarin should not be administered along with NSAIDs without careful consideration and monitoring due to the increased risk of bleeding. NSAIDs can affect platelet function and gastrointestinal mucosa, leading to an elevated risk of gastrointestinal bleeding when taken with warfarin¹¹¹².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Chronic back pain is not a specific symptom of SLE. While individuals with SLE may experience musculoskeletal pain, it is not as characteristic as other symptoms associated with the condition.
Choice B reason : A facial rash, particularly the classic "butterfly rash" that appears across the cheeks and bridge of the nose, is one of the hallmark signs of SLE. This rash is photosensitive and can be triggered or worsened by exposure to sunlight.
Choice C reason : Thickened skin is more commonly associated with systemic sclerosis (scleroderma) than with SLE. In SLE, skin involvement can include rashes and lesions, but not typically generalized skin thickening.
Choice D reason : Nausea is not a direct symptom of SLE, although it can be a side effect of medications used to treat SLE or may occur if the gastrointestinal system is affected by the disease.
Correct Answer is B
Explanation
Choice A reason : Avoiding exercise during flare-ups of fibromyalgia may seem intuitive to prevent exacerbating pain and fatigue. However, maintaining a gentle exercise routine, even during flare-ups, can help manage symptoms and prevent deconditioning¹.
Choice B reason : Establishing a regular sleep pattern is crucial for managing fibromyalgia. Poor sleep can exacerbate pain, fatigue, and cognitive difficulties commonly experienced with this condition. Good sleep hygiene practices can improve sleep quality and overall symptom management¹.
Choice C reason : While adequate calcium intake is essential for general health, there is no specific indication that increasing calcium intake alone would manage fibromyalgia symptoms. Nutritional needs should be addressed as part of a comprehensive approach to self-care¹.
Choice D reason : Yoga or running between flare-ups can be beneficial for clients with fibromyalgia. Regular exercise, including yoga, can improve pain, function, and quality of life. Running or other aerobic exercises can also be helpful if tolerated and done in moderation¹.
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