A nurse is providing discharge teaching to a client who has a gastric ulcer and a new prescription for esomeprazole.
Which of the following information should the nurse include in the teaching?

Choice A rationale

An INR (International Normalized Ratio) of 4.0 indicates that the client's blood is much thinner than the therapeutic range for most conditions (usually 2.0-3.0 for warfarin). This significantly increases the risk of bleeding. Vitamin K is the antidote for warfarin because it is essential for the synthesis of clotting factors (II, VII, IX, X) in the liver. Administering vitamin K reverses the anticoagulant effect of warfarin, reducing the risk of hemorrhage by promoting the production of functional clotting proteins.

Choice B rationale

Protamine sulfate is the antidote for heparin. It works by forming a stable ion pair with heparin, neutralizing its anticoagulant effects. It has no effect on the anticoagulant properties of warfarin, which acts by inhibiting vitamin K epoxide reductase, an enzyme crucial for the regeneration of active vitamin K necessary for clotting factor synthesis. Therefore, protamine is not indicated for warfarin overdose.

Choice C rationale

Calcium gluconate is used to treat hypocalcemia and magnesium toxicity. Calcium plays a vital role in numerous physiological processes, including bone health and muscle function, and is essential for blood coagulation. However, it does not directly counteract the effects of warfarin, which targets vitamin K-dependent clotting factors, and is not the appropriate antidote for an elevated INR.

Choice D rationale

Epinephrine is a potent vasoconstrictor and bronchodilator used in anaphylaxis, cardiac arrest, and severe asthma. It acts on alpha and beta-adrenergic receptors, leading to increased heart rate, blood pressure, and bronchodilation. It has no role in reversing the anticoagulant effects of warfarin and is not indicated for managing an elevated INR.

Choice A rationale

Alendronate is a bisphosphonate medication used to treat osteoporosis. It is known to be highly irritating to the esophageal mucosa, and if it lodges in the esophagus, it can cause severe esophagitis, ulceration, or erosion. Assessing the client's ability to swallow ensures safe passage of the medication and minimizes the risk of esophageal injury, highlighting a critical safety measure.

Choice B rationale

Alendronate should not be administered before bed. For optimal absorption and to minimize the risk of esophageal irritation, alendronate must be taken in the morning upon waking, at least 30 minutes before the first food, beverage, or medication. Taking it before bed increases the likelihood of the pill lingering in the esophagus, leading to irritation and potential injury.

Choice C rationale

Alendronate should not be administered with orange juice. The absorption of alendronate is significantly impaired by food, beverages other than plain water, and certain minerals like calcium. Orange juice contains calcium and can decrease the bioavailability of the medication, thereby reducing its therapeutic effectiveness. It must be taken with plain water only.

Choice D rationale

Informing the client to remain supine after taking the medication is incorrect. To facilitate rapid transit to the stomach and minimize esophageal contact, clients must remain upright (sitting or standing) for at least 30 minutes after taking alendronate, and until after their first food of the day. Lying down increases the risk of esophageal reflux and irritation.