A nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?
Platelets 190,000/mm3
Hct 44%
PT 45 seconds
Hgb 16 g/dL
The Correct Answer is C
Choice A reason: Platelets 190,000/mm3 is within the normal range of 150,000 to 450,000/mm3. This result does not indicate a bleeding risk or a need to adjust the warfarin dose.
Choice B reason: Hct 44% is within the normal range of 37% to 47% for females and 42% to 52% for males. This result does not indicate anemia or polycythemia, which could affect the warfarin therapy.
Choice C reason: PT 45 seconds is above the normal range of 11 to 13.5 seconds. This result indicates that the blood is taking too long to clot, which increases the risk of bleeding. The nurse should notify the provider and expect a decrease in the warfarin dose.
Choice D reason: Hgb 16 g/dL is within the normal range of 12 to 16 g/dL for females and 14 to 18 g/dL for males. This result does not indicate anemia or polycythemia, which could affect the warfarin therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A - Catheter Occlusion: This occurs when the catheter is blocked, preventing the flow of fluids or medication. It is usually indicated by difficulty in flushing the catheter or a slow drip rate¹. However, it does not typically cause a gurgling sound.
Choice B - (Catheter migration) is correct because when a central venous catheter (CVC) migrates from its original position, the tip can enter a smaller vein or a different location where turbulence occurs. This may cause the client to hear a gurgling or bubbling sound, especially during infusion or with position changes. Migration can happen due to coughing, movement, or changes in pressure, and it doesn’t necessarily involve the catheter being visibly out of place
Choice C - (Catheter dislodgment) is incorrect because dislodgment typically refers to the catheter being partially pulled out of the insertion site. This would be more likely to cause external signs like visible catheter movement or fluid leakage at the insertion site, rather than internal gurgling sounds. Gurgling is more associated with internal changes in catheter position, as seen with migration.
Choice D - Catheter Rupture: This is a break or tear in the catheter. It can cause serious complications, including infection and embolism. However, a gurgling sound is not a typical symptom of a catheter rupture¹.
Correct Answer is C
Explanation
Choice A reason: Vitamin K is the antidote for warfarin, not heparin. Vitamin K reverses the effects of warfarin by increasing the synthesis of clotting factors in the liver.
Choice B reason: Glucagon is the antidote for insulin, not heparin. Glucagon increases the blood glucose level by stimulating the breakdown of glycogen in the liver.
Choice C reason: Protamine is the antidote for heparin, not vitamin K or glucagon. Protamine neutralizes the effects of heparin by binding to it and forming a stable complex.
Choice D reason: Iron is not an antidote for any anticoagulant. Iron is a mineral that is essential for the production of hemoglobin and red blood cells.
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