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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Oil-based lubricant: Oil-based lubricants are not recommended for nasogastric tube insertion because they can increase the risk of aspiration pneumonia if inadvertently inhaled. Water-soluble lubricants are preferred, as they are safer if aspirated and do not interfere with mucosal integrity.

B. Enteric feeding pump: An enteric feeding pump is used for controlled delivery of enteral nutrition, not for gastric decompression. Gastric decompression typically involves connecting the tube to low intermittent suction to remove air or gastric contents.

C. Sterile gloves: Clean, not sterile, gloves are generally sufficient for nasogastric tube insertion unless the client is immunocompromised or a sterile field is otherwise required. The procedure does not involve entering a sterile body cavity.

D. pH strips: pH strips are essential to verify correct placement of the nasogastric tube by testing the acidity of aspirated gastric contents. Gastric fluid typically has a pH of 5 or less, which helps confirm proper positioning before initiating suction or other interventions.

A. The television set is turned to a loud volume. B. The dining room table has low chairs with no armrests. C. The bedroom extension cord is placed under a heavy nightstand. D. The living room contains wall-to-wall carpeting.

Correct Answer is C

Explanation

A. The television set is turned to a loud volume: While a loud television may contribute to auditory fatigue or difficulty communicating, it does not present an immediate physical safety hazard. It does not increase the risk of falls, electric shock, or fire, so it generally does not require urgent intervention.

B. The dining room table has low chairs with no armrests: Low chairs without armrests may make it slightly more difficult for some individuals to sit or stand, particularly older adults or those with mobility issues. However, this is not an urgent safety hazard, and adaptations can be addressed gradually without immediate risk of injury.

C. The bedroom extension cord is placed under a heavy nightstand: Placing an extension cord under a heavy object poses a significant safety risk. Pressure on the cord can damage the insulation, increasing the risk of electrical shock or fire. Additionally, the cord may overheat or fray over time, making this a high-priority intervention to prevent injury or property damage.

D. The living room contains wall-to-wall carpeting: Wall-to-wall carpeting generally provides a non-slip surface that can reduce the risk of falls. While it may harbor dust or allergens, it does not constitute an immediate safety hazard requiring intervention.

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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?

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