The nurse is caring for a client who experienced a severe headache. When the prescribed dose of analgesics did not cause relief, the client took double the dosage 1 hour later. The nurse should assess the client for what adverse effect?
An allergic reaction
Anaphylactic reaction
Poisoning
Sedative effects
The Correct Answer is C
A. An allergic reaction is a possible response to medication, but it is not directly related to doubling the dosage.
B. Anaphylactic reaction is a severe and rapid allergic response; while possible, it is not the most likely consequence of an overdose in this context.
C. Poisoning is a likely concern when a client takes double the prescribed dosage of analgesics, especially if the medication has a narrow therapeutic index or is known to cause toxicity at high doses.
D. Sedative effects could occur depending on the analgesic used, but poisoning is a more pressing concern following an overdose.
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Correct Answer is A
Explanation
A. An INR of 5.0 indicates a significantly increased risk of bleeding, and administering vitamin K is the appropriate antidote for reversing the effects of warfarin. This is a critical intervention to restore coagulation.
B. Increasing the dose of warfarin is inappropriate in this scenario because the INR is already elevated; it would further increase bleeding risk.
C. While heparin can be used for anticoagulation, it is not appropriate to administer it while the INR is dangerously high without reversing the warfarin first.
D. Continuing warfarin is unsafe at this INR level due to the high risk of bleeding; monitoring for symptoms without intervention is not adequate care.
Correct Answer is A
Explanation
A. Try not to swallow while the pill dissolves is correct because sublingual medications are designed to be absorbed directly into the bloodstream through the mucous membranes under the tongue, and swallowing may hinder this absorption.
B. Take a big drink of water and swallow the pill is incorrect because sublingual medications should not be swallowed with water as they need to dissolve under the tongue.
C. Swallow frequently to get the best benefit is incorrect, as this can interfere with the absorption of the medication.
D. Chew the pill so it will dissolve faster is incorrect since chewing may destroy the sublingual formulation, preventing it from working as intended.