The patient taking warfarin for prevention of deep vein thrombosis has an INR of 1.2. Which action by the nurse is most appropriate?

Correct Answer: D

Rationale: In the context of pediatric nursing and the administration of warfarin, a low INR of 1.2 indicates that the patient's blood is not adequately anticoagulated, putting them at risk for clot formation. The most appropriate action by the nurse is to call the healthcare provider to increase the dose of warfarin. This is because the current dose is not achieving the desired therapeutic effect, and an adjustment is needed to reach the target INR range. Option A, administering IV push protamine sulfate, is incorrect as protamine sulfate is used to reverse the effects of heparin, not warfarin. Continuing with the current prescription (Option B) would not address the subtherapeutic INR level. Option C, preparing to administer Vitamin K, is not the first-line intervention for a low INR in a patient taking warfarin; it is typically reserved for cases of warfarin overdose or when there is excessive anticoagulation leading to bleeding. In a pediatric nursing context, it is crucial to understand the appropriate actions to take when managing anticoagulation therapy in children to ensure their safety and well-being. Monitoring and adjusting warfarin doses based on INR levels are essential components of pediatric nursing care to prevent complications such as thrombosis or bleeding events.

Correct Answer: D

Rationale: The correct answer is D: BP of 70/50. When sildenafil (Viagra) is taken with nitroglycerin, it can cause severe hypotension that is unresponsive to treatment. The combination of these medications can lead to a dangerous drop in blood pressure. It is crucial to immediately report hypotension in this scenario. It is recommended to allow at least 24 hours to elapse between the last dose of sildenafil and nitroglycerin to prevent such adverse effects. The other vital signs and lab values may be abnormal but do not have the immediate life-threatening implications that severe hypotension does in this context.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Potassium. When a patient is taking glucocorticoids and digoxin, the nurse should prioritize monitoring potassium levels. Glucocorticoids can cause potassium depletion, leading to hypokalemia. Digoxin, on the other hand, can cause toxicity, especially in the presence of low potassium levels, which can potentiate its effects on the heart and increase the risk of serious cardiac arrhythmias. A) Calcium is not the most critical electrolyte to monitor in this case. While it is important for muscle and nerve function, it is not directly affected by the combination of glucocorticoids and digoxin. B) Magnesium is also important for muscle and nerve function, but it is not the priority electrolyte to monitor when a patient is taking glucocorticoids and digoxin. C) Sodium levels are typically not significantly impacted by glucocorticoids and digoxin in a way that would necessitate prioritizing monitoring compared to potassium in this specific scenario. Educationally, understanding the interactions between medications and electrolyte imbalances is crucial for pediatric nurses. This knowledge helps in providing safe and effective care to pediatric patients, especially those on multiple medications with potential interactions. Prioritizing monitoring based on these interactions can prevent complications and improve patient outcomes.

Correct Answer: B

Rationale: The patient is exhibiting symptoms of anaphylaxis triggered by a peanut allergy, which is a severe and potentially life-threatening allergic reaction. The appropriate medication for anaphylaxis is epinephrine. Epinephrine acts quickly to reverse the symptoms by constricting blood vessels, relaxing bronchial muscles, and reducing laryngeal edema, making it the drug of choice for this situation. Promethazine, diphenhydramine, and hydroxyzine are not the first-line treatments for anaphylaxis and may not address the severe manifestations seen in this case.

Correct Answer: B

Rationale: In this scenario, the most important question for the nurse to ask the patient with Parkinson's disease who is taking levodopa/carbidopa (Sinemet) is option B: "Are you having vivid dreams or hallucinations?" This question is crucial because levodopa, a common medication for Parkinson's disease, can lead to side effects such as vivid dreams or hallucinations. It is essential for the nurse to assess for these symptoms as they can impact the patient's overall well-being and quality of life. Option A, asking about swelling in the feet, is less relevant in this case as it is not a common side effect of levodopa/carbidopa. Option C, inquiring about changes in stool, is also less important as it is not directly related to the medication or the management of Parkinson's disease. Option D, asking about the flu vaccine, while important for overall health, is not as pertinent during a semi-annual physical examination specifically for a patient with Parkinson's disease on levodopa/carbidopa. Educationally, this question highlights the importance of understanding common side effects of medications used to treat specific conditions. It emphasizes the need for nurses to be knowledgeable about potential medication side effects and to prioritize assessments based on the specific medications and conditions their patients have. This rationale underscores the significance of comprehensive patient assessments in providing safe and effective care.