A nurse is teaching a client who has heart failure and is prescribed captopril. Which of the following instructions should the nurse include? (Select all that apply.).

The client has a blood pressure of 120/78 mm Hg. This indicates that the medication is effective because it lowers the blood pressure below the hypertensive levels.In adults 60 years of age or older, this is typically defined as a systolic pressure below 150 mm Hg and a diastolic pressure below 90 mm Hg.

Choice A is wrong because the client has no edema in the lower extremities. This is not a specific outcome of lisinopril, an angiotensin II receptor blocker (ARB). Edema can be caused by many factors, such as heart failure, kidney disease, or venous insufficiency. Lisinopril does not directly affect fluid retention or edema.

Choice B is wrong because the client has a urine output of 30 mL/hr. This is a low urine output that may indicate dehydration, kidney impairment, or urinary obstruction. Lisinopril is expected to increase urine output by reducing the blood pressure and improving the renal blood flow.

Choice D is wrong because the client has a serum creatinine level of 1.2 mg/dL. This is a high serum creatinine level that may indicate kidney damage or reduced kidney function. Lisinopril is expected to lower the serum creatinine level by preventing the progression of kidney disease and protecting the kidney from further injury.

Normal ranges of urine output, blood pressure, and serum creatinine are:

• Urine output: 800 to 2000 mL/day or 40 to 80 mL/hr

• Blood pressure: less than 120/80 mm Hg for adults

• Serum creatinine: 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females

Warfarin is an anticoagulant that prevents blood clots from forming or growing larger. It works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver. The INR (international normalized ratio) is a measure of how long it takes the blood to clot.The therapeutic range for INR depends on the indication for warfarin therapy, but for atrial fibrillation, it is usually between 2 and 3. An INR level of 3.5 is above the therapeutic range, which means the blood is too thin and the patient is at risk of bleeding. The nurse should hold the warfarin dose and notify the physician, who may order vitamin K to reverse the effects of warfarin.

Choice A) Administer vitamin K as ordered by physician is wrong because vitamin K is not indicated unless the physician orders it based on the patient’s condition and INR level.

Vitamin K is an antidote for warfarin overdose and can reverse its anticoagulant effects.

However, administering vitamin K without a physician’s order may cause the INR to drop below the therapeutic range and increase the risk of clotting.

Choice B) Administer heparin as ordered by physician is wrong because heparin is another anticoagulant that works by activating antithrombin, a natural inhibitor of clotting factors.

Heparin is used for acute treatment of thromboembolic disorders, such as deep vein thrombosis or pulmonary embolism.

It is not indicated for atrial fibrillation unless there is evidence of acute thrombosis.

Administering heparin to a patient with an elevated INR would increase the risk of bleeding.

Choice C) Administer warfarin as ordered by physician is wrong because warfarin is the cause of the elevated INR and should be withheld until the INR returns to the therapeutic range.

Continuing to administer warfarin would further increase the INR and the risk of bleeding.