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?.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Remove gloves, wash hands, remove face shield, gown, mask, and wash hands again. This is because gloves are the most contaminated piece of PPE and should be removed first to avoid touching other parts of the body or environment with them. Washing hands after removing gloves is also important to reduce the risk of infection. Face shields, gowns, and masks should be removed in that order, as they are less contaminated than gloves and can be handled with clean hands. Washing hands again after removing all PPE is the final step to ensure hygiene.
Choice A is wrong because it does not include washing hands after removing gloves, which is a crucial step to prevent contamination. It also removes the gown before the gloves, which can cause the gown to touch the face or hair and contaminate them.
Choice B is wrong because it does not include washing hands between removing gloves and gown, which can transfer germs from the gloves to the gown and then to the face or hair when removing the face shield and mask.
Choice D is wrong because it does not include washing hands between removing gloves and gown, which can transfer germs from the gloves to the gown and then to the face or hair when removing the face shield and mask. It also removes the gown before the face shield, which can cause the gown to touch the face or hair and contaminate it.
Normal ranges for PPE removal are not applicable as different types of PPE may require different methods of removal. However, some general principles are to remove PPE in a way that minimizes contact with contaminated surfaces, perform hand hygiene frequently, and dispose of PPE properly.
Correct Answer is D
Explanation
Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.
This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.
Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.
Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.
Pedal pulses are important indicators of peripheral circulation and vascular status.
Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.
First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.
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