A client who is taking warfarin has an international normalized ratio (INR) of 0.8. Which question should a nurse ask to further evaluate the client?

Do your gums bleed when you brush your teeth?.

Are you taking the medication as prescribed?.

Have you noticed blood in your stools?.

Do you have any unusual bruising?.

Answer and Explanation

The Correct Answer is B

Are you taking the medication as prescribed? This is because warfarin is a blood-thinning medication that affects the prothrombin time (PT) and the international normalized ratio (INR).

The PT measures how long it takes for blood to clot, and the INR is a calculation based on the PT that standardizes the results across different laboratories. A normal INR range is 0.8 to 1.1 for people who are not taking warfarin. People who take warfarin usually have a target INR range of 2 to 3, depending on their condition.

An INR of 0.8 means that the blood clots faster than normal, which increases the risk of blood clots and strokes.

This could indicate that the client is not taking enough warfarin or is taking other medications or foods that interfere with warfarin’s effect.

Choice A is wrong because bleeding gums are a sign of excessive bleeding, which could happen if the INR is too high, not too low.

Choice C is wrong because blood in stools is also a sign of excessive bleeding, which could happen if the INR is too high, not too low.

Choice D is wrong because unusual bruising is another sign of excessive bleeding, which could happen if the INR is too high, not too low.

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Correct Answer is B

Explanation

This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-

being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.

Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.

It is not a priority over fluid volume deficit.

Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.

Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.

A. Call for assistance. B. Give 2 rescue breaths. C. Check for apical pulse. D. Begin chest compressions.

Correct Answer is A

Explanation

This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.

Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.

Giving rescue breaths to a client who has a pulse may cause harm.

Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.

Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.

Chest compressions may cause harm to a client who has a pulse.

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A client who is taking warfarin has an international normalized ratio (INR) of 0.8. Which question should a nurse ask to further evaluate the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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