A client taking warfarin presents with bruises, dark tarry stools, and an international normalized ratio (INR) of 4.3. What is the nurse's action?
Explain to the client the nurse may ask the provider to order a test for leukemia.
Hold the warfarin and consult the provider regarding the next steps.
Give an ampule of Vitamin K, then call the physician to report client status.
Give the warfarin with a dark green salad and check the next stool for blood.
The Correct Answer is B
a. The symptoms described (bruises, dark tarry stools, elevated INR) are indicative of warfarin overdose or excessive anticoagulation, not leukemia.
b. This is the correct answer because holding the warfarin is necessary to prevent further bleeding complications, and consulting the provider is essential for guidance on the next steps.
c. Giving Vitamin K may be necessary in cases of severe bleeding due to warfarin, but it is not the initial action. Consulting the provider is the priority.
d. Giving warfarin with a dark green salad may exacerbate the situation and increase the risk of bleeding. Checking the next stool for blood does not address the immediate issue of anticoagulation excess.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Taking levothyroxine at bedtime may affect sleep, but this statement suggests an incorrect understanding of the dosing schedule.
B) Taking levothyroxine with a meal may interfere with its absorption. The medication is generally recommended to be taken on an empty stomach.
C) Taking levothyroxine before breakfast on an empty stomach is the standard recommendation for optimal absorption.
D) Stopping levothyroxine based on TSH levels should be done under the guidance of a healthcare provider, and it's not a routine approach to medication administration.
Correct Answer is ["D"]
Explanation
The blood glucose reading before lunch falls within the range of 201-250 mg/dl according to the sliding scale, and the corresponding instruction is to give six units of lispro insulin.
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