A client with a deep vein thrombosis has been receiving warfarin sodium 2.5 mg PO daily. The client's International Normalized Ratio (INR) is 5.0. The nurse is aware that the medication dose needs to be:

increased.

given as prescribed.

cut in half.

held.

Answer and Explanation

The Correct Answer is D

A.   An INR of 5.0 indicates that the blood is significantly thinner than the therapeutic range (typically 2.0 to 3.0 for DVT treatment). Increasing the dose of warfarin would further increase the risk of bleeding.
B.   Continuing with the prescribed dose of 2.5 mg is not appropriate at this time. The INR is above the safe therapeutic range, indicating a need for adjustment, not maintenance of the current dose.
C.   While reducing the dose may be necessary, cutting it in half may not adequately address the high INR. The more appropriate action would involve holding the dose or significantly adjusting it based on the INR and clinical guidelines.
D.   An INR of 5.0 is a critical value that suggests the client is at an increased risk of bleeding. The appropriate action in this case is to hold the warfarin dose and notify the healthcare provider for further evaluation and management. Depending on clinical protocols, the provider may recommend administering vitamin K to reverse the effects of warfarin, especially if there are signs of bleeding or if the INR is critically high.

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Correct Answer is C

Explanation

A. While positioning a patient prone can help with certain surgical recovery situations, it is not typically used immediately after an above-the-knee amputation. Additionally, elevating the arms may not provide any benefit and could cause discomfort.
B. This position can increase the risk of contractures in the residual limb, especially with an above-the- knee amputation. Keeping the stump flat may also lead to swelling and discomfort.
C. This position allows for proper elevation of the stump, which can help reduce swelling and promote healing. Supporting the stump on pillows prevents the risk of contractures and maintains the limb in a neutral position. It provides comfort and stability while facilitating blood flow.
D. While this position can help with venous return and reduce the risk of complications such as orthostatic hypotension, it is not specifically beneficial for an above-the-knee amputation recovery. It may not adequately address the need for proper stump support and elevation.

A. take vital signs. B. administer 1 mg glucagon subcutaneously. C. obtain a blood glucose reading. D. notify the physician.

Correct Answer is C

Explanation

A. While taking vital signs can provide useful information about the client's overall condition, it does not address the immediate concern of potential hypoglycemia. The priority is to assess blood glucose levels directly.
B. Glucagon can be administered in cases of severe hypoglycemia where the patient is unable to ingest glucose orally. However, before administering glucagon, the nurse should first check the blood glucose level to confirm hypoglycemia.
C. Checking the blood glucose level will provide immediate information about whether the client is experiencing hypoglycemia. If the blood glucose is low, appropriate treatment (such as administering glucose or a fast-acting carbohydrate) can be initiated. If it’s within normal limits, other causes for the symptoms can be explored.
D. While it may be necessary to notify the physician depending on the outcome of the blood glucose reading or if the client’s condition worsens, it is not the first action. Immediate assessment of the blood glucose level is essential to determine the correct course of action.

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A client with a deep vein thrombosis has been receiving warfarin sodium 2.5 mg PO daily. The client's International Normalized Ratio (INR) is 5.0. The nurse is aware that the medication dose needs to be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has returned to the nursing unit from the post anesthesia care unit (PACU) 40 minutes ago following an above the knee amputation (AKA) of the right leg. In which position should the nurse place the client at this time?

Correct Answer is C

Explanation

A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to:

Correct Answer is C

Explanation

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