Nokea
A client with thrombotic stroke is administered ticlopidine. The nurse would assess the client for which of the following?
- A. Dyspepsia
- B. Dyspnea
- C. Hematoma
- D. Bradycardia
Correct Answer: A
Rationale: The nurse should monitor for dyspepsia in the client who has been administered ticlopidine. Hematoma is an adverse reaction to heparin. Dyspnea is an adverse reaction to protamine sulfate and treprostinil. Bradycardia is an adverse reaction to protamine sulfate.
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When teaching a class about parenterally administered heparin, which of the following would the nurse include? Select all that apply.
- A. Onset of action is almost immediate.
- B. Maximum effect occurs within 10 minutes.
- C. It is preferably given intramuscularly.
- D. Clotting time returns to normal within 4 hours.
- E. It causes fewer adverse reactions than the oral form.
Correct Answer: A,B,D
Rationale: Parenteral heparin results in an almost immediate onset of action with a maximum effect within 10 minutes, but clotting returns to normal within 4 hours unless subsequent doses are given. It is preferably given subcutaneously or intravenously.
A client is prescribed an anticoagulant. In which of the following situations would the nurse hold the drug and notify the physician? Select all that apply.
- A. PT exceeds 1.5 times the control value.
- B. PT is less than 1.5 times the control value.
- C. There is evidence of bleeding.
- D. INR is less than 3.0.
- E. INR is greater than 3.0.
Correct Answer: A,C,E
Rationale: The nurse should withhold the drug and contact the physician if any of the following occur: the PT exceeds 1.5 times the control value, there is evidence of bleeding, or the INR is greater than 3.0.
The nurse instructs a client receiving warfarin about the importance of consistent intake of dietary vitamin K to decrease fluctuations in PT/INR. The nurse determines that the client understands the instructions when he identifies which foods as containing vitamin K? Select all that apply.
- A. Broccoli
- B. Cauliflower
- C. Fish
- D. Yogurt
- E. Chicken
Correct Answer: A,B,C,D
Rationale: Foods high in vitamin K include leafy green vegetables, beans, broccoli, cabbage, cauliflower, cheese, fish, and yogurt.
A nurse is caring for a client receiving the anticoagulant drug warfarin. Which assessment would be most appropriate before administering the drug?
- A. Observe for signs of thrombus formation.
- B. Assess prothrombin time (PT) and INR.
- C. Assess for signs of bleeding.
- D. Monitor for hypersensitivity reaction.
Correct Answer: B
Rationale: The nurse should assess the prothrombin time (PT) and INR before administering the anticoagulant drug warfarin to the client.
A female client is prescribed warfarin. The client also uses oral contraceptives. The nurse would assess the client closely for which of the following? Select all that apply.
- A. Bruising
- B. Blood in the stool
- C. Subtherapeutic INR
- D. Supratherapeutic INR
- E. Calf pain and warmth
Correct Answer: C,E
Rationale: Coadministration of warfarin and oral contraceptives can result in a decreased anticoagulant effect, leading to subtherapeutic INR and increased chance of clotting (signs and symptoms of DVT or PE).