A patient inadvertently took an excessive dose of warfarin (Coumadin) and was immediately treated with IV vitamin K (Phytonadione). The symptoms that would most concern the nurse after administration of vitamin K are
a. mild pruritus, pulse of 92.
b. respirations of 32, bronchoconstriction, O2 sats of 83%.
c. prolonged sensitization to warfarin (Coumadin).
d. blood pressure of 107/52 and bleeding gums.
B
The patient is experiencing a hypersensitivity reaction to the phytonadione, which is manifested by impending respiratory distress associated with IV administration of the drug.
Mild pruritus may be significant, but the pulse is within normal limits. The greatest concerns are the low O2 sats and bronchoconstriction.
There is no indication of how long the patient was exposed to warfarin, therefore sensitization is not a correct choice.
A blood pressure of 107/52 is not significant, because it may be baseline for the patient. Bleeding gums are an anticipated effect of excessive warfarin and would not be a significant finding after administration of the vitamin K.
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