Nokea
A patient is receiving an IV infusion of a thrombolytic drug during treatment for an acute MI. The nurse notices that there is a slight amount of bleeding from the antecubital area where venous lab work was drawn. What will the nurse do first?
- A. Monitor the site for further bleeding.
- B. Apply pressure to the site with a gauze pa
- D. Slow the rate of infusion of the thrombolytic drug.
Correct Answer: B
Rationale: Applying pressure to the site with a gauze pad is the first action the nurse should take when noticing bleeding from the antecubital area. This will help control the bleeding and prevent further blood loss. Monitoring the site for further bleeding is important, but immediate intervention by applying pressure is necessary to address the issue. Slowing the rate of infusion of the thrombolytic drug or stopping the infusion should be considered if bleeding continues despite applying pressure or if there are signs of significant bleeding or hemorrhage.
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Which of the following medications would you administer for an overdose of acetaminophen?
- A. Naloxone
- B. Vitamin K
- C. Acetylcysteine
- D. Atropine
Correct Answer: C
Rationale: Acetylcysteine is the antidote for an acetaminophen overdose. Acetaminophen overdose can cause liver damage due to its toxic metabolite buildup in the liver. Acetylcysteine works by replenishing glutathione, which helps in detoxifying the toxic metabolite of acetaminophen. Administering acetylcysteine within 8-10 hours of the overdose is crucial in preventing severe liver damage and improving the patient's outcome. Naloxone is used for opioid overdose, Vitamin K for treating specific types of bleeding disorders, and Atropine for drug poisoning or certain types of poisoning, but they are not indicated for an acetaminophen overdose.
The patient accidentally takes too much of the prescribed warfarin (Coumadin) and is readmitted to the hospital with bleeding. Which drug can the nurse anticipates administrating?
- A. Protamine sulfate
- B. Alteplase (Activase, Cathflo Activas
- D. Reteplase (Retavas
Correct Answer: D
Rationale: Warfarin, also known as Coumadin, is an anticoagulant medication that works by inhibiting the production of clotting factors in the liver, specifically factors II, VII, IX, and X. In the event of warfarin overdose, which can lead to excessive bleeding, the antidote is vitamin K. Vitamin K promotes the production of these clotting factors and helps reverse the effects of warfarin. Therefore, in this situation, the nurse can anticipate administering vitamin K to the patient to help stop the bleeding caused by the excess warfarin in the system.
A child was brought to the emergency room complaining of right upper quadrant abdominal pain, nausea, and vomiting. Upon the interview of the nurse to the mother, the client has been taking a long-
- A. Which of the following medications should be readily available?
- B. naltrexone (ReVi
- C. urea (Ureaphil)
- D. acetylcysteine (Mucomyst)
Correct Answer: A
Rationale: The presentation of right upper quadrant abdominal pain, nausea, and vomiting in a child with a history of taking a long-acting formulation of valproic acid (Depakene) is concerning for valproic acid overdose. Valproic acid toxicity can lead to liver damage, which may present with symptoms such as abdominal pain, nausea, and vomiting. In cases of valproic acid overdose, acetylcysteine (Mucomyst) is commonly used as a treatment to help prevent or reduce liver damage by replenishing glutathione stores and acting as a reactive oxygen species scavenger. Therefore, acetylcysteine should be readily available in this scenario to initiate prompt treatment and potentially prevent severe liver injury.
A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote?
- A. Vitamin E
- B. Vitamin K
- C. Protamine sulfate
- D. Potassium chloride
Correct Answer: B
Rationale: Vitamin K is the antidote for warfarin (Coumadin) toxicity. Warfarin is a vitamin K antagonist that inhibits the synthesis of vitamin K-dependent coagulation factors (II, VII, IX, X) in the liver. In cases of excessive anticoagulation and bleeding, administering vitamin K can help reverse the effects of warfarin by replenishing the depleted vitamin K-dependent clotting factors. Vitamin K helps the liver produce clotting factors, thereby promoting the clotting process and reversing the excessive anticoagulant effects of warfarin. Other options mentioned, such as Vitamin E, Protamine sulfate, and Potassium chloride, are not appropriate antidotes for warfarin toxicity.
For the patient taking acetaminophen, what should the nurse do? (Select all that apply.)
- A. Monitor routine liver enzyme tests.
- B. Encourage the patient to check package labels of over-the-counter drugs to avoid overdosing.
- C. Report side effects immediately, as toxicity can cause severe hepatic damage.
- D. Teach the female patient that oral contraceptives can increase the effect of acetaminophen.
Correct Answer: D
Rationale: Acetaminophen is metabolized in the liver, and excessive doses can lead to hepatotoxicity. Routine monitoring of liver enzymes is essential to detect early signs of liver damage. Patients should also be educated to check the acetaminophen content in over-the-counter medications to avoid accidental overdose. Reporting side effects promptly is crucial, as acetaminophen toxicity can cause severe and potentially fatal liver damage. While oral contraceptives can affect drug metabolism, they do not significantly increase the effects of acetaminophen. Therefore, the correct actions are to monitor liver enzymes, educate about over-the-counter medications, and report side effects.