A nurse is collecting data from a client who is taking warfarin and reports observing blood in their stools. Which of the following actions should the nurse take?
Prepare the client for a barium enema.
Prepare the client for a colonoscopy.
Request an aPTT level.
Request an INR level.
The Correct Answer is D
A. Prepare the client for a barium enema: A barium enema is a diagnostic imaging procedure used to evaluate structural abnormalities in the colon, but it is not the immediate priority when a client on warfarin reports blood in stools. The focus should first be on assessing coagulation status and risk of bleeding.
B. Prepare the client for a colonoscopy: Colonoscopy allows direct visualization of the colon to identify sources of bleeding, but performing an invasive procedure in a client on anticoagulation without assessing clotting parameters first increases the risk of severe hemorrhage. Immediate evaluation of anticoagulation levels is safer.
C. Request an aPTT level: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin. Checking aPTT would not provide accurate information about the client’s anticoagulation status or bleeding risk with warfarin therapy.
D. Request an INR level: The international normalized ratio (INR) is the standard laboratory test for monitoring warfarin therapy. An elevated INR indicates increased anticoagulation and a higher risk of bleeding. Assessing the INR provides critical information to guide interventions such as dose adjustment or vitamin K administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Allow the infant to have soft foods: After cleft palate repair, oral intake is typically restricted to prevent trauma to the surgical site. Soft or solid foods can disrupt sutures and increase the risk of bleeding or infection. Oral intake is usually limited to clear liquids or specially prepared feeds until healing is sufficient.
B. Maintain elbow restraints on the infant: Elbow restraints (arm splints) help prevent the infant from touching or putting fingers or objects in the mouth, which could damage the surgical site. This intervention protects the integrity of the repair during the critical postoperative healing period and reduces the risk of complications such as dehiscence or infection.
C. Instruct the parents to feed the infant with a spoon: Spoon feeding can apply pressure to the palate and sutures, potentially causing trauma to the repair site. Feeding is often done using specialized devices such as a syringe, cup, or soft-tipped feeders designed to minimize contact with the surgical area.
D. Tell the parents to avoid brushing the infant's teeth for two weeks: Oral hygiene is still important after cleft palate repair, but brushing must be gentle to avoid trauma. Complete avoidance is unnecessary; instead, the nurse should instruct parents to use soft-bristled brushes and avoid the immediate surgical site while maintaining overall oral cleanliness.
Correct Answer is B
Explanation
A. "You can resume a regular diet 3 days after your procedure.": Most adolescents can resume their regular diet shortly after a cardiac catheterization once vital signs are stable and there are no complications. Delaying diet for 3 days is unnecessary unless the provider specifies restrictions due to other medical conditions.
B. "You can take a shower 1 day after your procedure.": Showering is generally allowed 24 hours after cardiac catheterization, provided the dressing over the insertion site remains dry and intact. This instruction promotes hygiene while minimizing the risk of infection at the puncture site.
C. "You can begin exercising 2 days after your procedure.": Physical activity is typically restricted for several days to a week after catheterization to allow the vascular access site to heal and reduce the risk of bleeding or hematoma formation. Exercising too soon could compromise site integrity.
D. "You can return to school 1 week after your procedure.": Returning to school may depend on the adolescent’s overall recovery and provider instructions. While many can resume school within a few days, the primary focus immediately after the procedure is ensuring safe hygiene and access site healing rather than full activity, making showering the first priority instruction.
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