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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

a) Pain in a client with a history of rheumatoid arthritis is important but may not require immediate attention compared to potential complications of medication administration.

b) Preparing a client for a chlorhexidine scrub is important, but it is not an immediate priority compared to potential complications related to medication and vital signs.

c) A client who cannot have anything by mouth before surgery and received insulin glargine the night before needs monitoring, but it may not require immediate assessment compared to the potential complications of the client receiving digoxin with a blood pressure of 100/75 mmHg.

d) The client receiving digoxin with a blood pressure of 100/75 mmHg is at risk for toxicity, as low blood pressure may increase the concentration of digoxin. This client should be assessed first to prevent potential complications.

A. The temperature is above 100.4 degrees Fahrenheit (38 degrees Celsius). B. The blood pressure is above 140 mm Hg systolic. C. Respiratory rate of 10 breaths per minute with an oxygen saturation level of 86%. D. The heart rate is above 90 beats per minute.

Correct Answer is C

Explanation

A) Elevated temperature is not a typical reason to withhold morphine unless there are other concerns, such as infection.

B) Elevated blood pressure alone is not a reason to withhold morphine, but it should be considered in the context of the overall clinical picture.

C) A respiratory rate of 10 breaths per minute with low oxygen saturation indicates respiratory depression, which is a significant concern and a reason to withhold morphine.

D) An elevated heart rate alone is not a reason to withhold morphine, but it should be considered in the context of the overall clinical picture.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Which of these situations would cause the nurse to hold a dose of morphine?

Correct Answer is C

Explanation

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