Following three days of nausea, vomiting, and diarrhea, an older adult is admitted with severe dehydration. After two attempts, the nurse secured venous access using a 24-gauge IV catheter and began infusing 0.9% normal saline at 150 mL/hour. Minutes later, the client reports pain at the IV site. Which intervention should the nurse implement first?

Choice A reason: Administering warfarin with an INR of 4.8 is dangerous, as it exceeds the therapeutic range (2.0–3.0), indicating excessive anticoagulation. This risks bleeding, as warfarin inhibits vitamin K-dependent clotting factors. Notifying the provider ensures dose adjustment or reversal, preventing hemorrhage, making this action unsafe.

Choice B reason: An INR of 4.8 indicates over-anticoagulation in atrial fibrillation, increasing bleeding risk due to warfarin’s inhibition of clotting factors. Notifying the provider is critical for dose reduction or vitamin K administration, addressing the pathophysiological risk of hemorrhage, ensuring patient safety and preventing life-threatening complications.

Choice C reason: Encouraging green leafy vegetables, high in vitamin K, counteracts warfarin, lowering INR, but is inappropriate without provider guidance at INR 4.8, risking bleeding. Provider notification ensures controlled management, as unregulated dietary changes disrupt anticoagulation stability, making this action potentially harmful.

Choice D reason: Monitoring for bleeding is important but secondary to notifying the provider at INR 4.8, indicating critical over-anticoagulation. Immediate provider intervention adjusts warfarin or administers reversal agents, preventing hemorrhage. Monitoring delays urgent action needed to correct the clotting factor imbalance, making it less immediate.

Choice A reason: Placing the chair by the bed is preparatory but not immediate after sitting up. Prolonged bedrest risks orthostatic hypotension from reduced plasma volume and baroreceptor sensitivity. Assessing the client’s response ensures stability before transfer, preventing falls, making this less urgent than evaluating for dizziness or hypotension.

Choice B reason: Supporting the client when rising is premature before assessing their response to sitting. Bedrest causes deconditioning, increasing orthostatic hypotension risk, leading to dizziness or syncope. Determining how the client feels confirms cardiovascular stability, preventing falls during transfer due to blood pressure drops.

Choice C reason: Determining how the client feels assesses for orthostatic hypotension, common post-bedrest due to reduced venous return and baroreceptor dysfunction. Dizziness or lightheadedness signals syncope risk during transfer. This ensures cardiovascular stability, prioritizing safety before physical support, addressing physiological changes from prolonged immobility.

Choice D reason: Offering non-skid socks prevents falls during ambulation but is secondary to assessing sitting response. Bedrest heightens hypotension risk, and ensuring the client is not dizzy takes precedence to avoid syncope. Socks are a later safety measure, making this less immediate than evaluating physiological stability.