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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason : A nagging cough can be a warning sign of cancer, particularly lung cancer. If a cough persists for weeks or longer, especially if it's accompanied by blood or sputum, it should be evaluated by a healthcare professional. Persistent coughing can also be symptomatic of laryngeal or thyroid cancer¹.

Choice B reason : A nonhealing sore that persists for more than a few weeks can be a sign of skin cancer, including melanoma, basal cell carcinoma, or squamous cell carcinoma. It's also a common sign of oral cancer, especially in individuals who use tobacco or consume excessive alcohol¹.

Choice C reason : A change in moles or other skin lesions can be an early indication of skin cancer. The ABCDE rule is a guide to the usual signs of melanoma, looking for Asymmetry, Border irregularity, Color changes, Diameter greater than 6mm, and Evolving size, shape or color².

Choice D reason : While bloating can be caused by many benign conditions, persistent bloating that doesn't go away can be a sign of ovarian or other types of abdominal cancers. It's important to consider this symptom in conjunction with other signs and symptoms¹.

Choice E reason : A change in bowel pattern, such as persistent diarrhea or constipation, can indicate colorectal cancer. Any significant changes in bowel habits that do not resolve over time warrant medical evaluation¹.

A. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level." B. "A pharmacist is the person to answer that question." C. "Heparin does not dissolve clots. It stops new clots from forming." D. "The oral medication you will take after this IV will dissolve the clot."

Correct Answer is C

Explanation

Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.

Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.

Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.

Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.

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