The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?

Obtain another blood sample.

Give the next scheduled dose.

Monitor for signs of bleeding.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

A. An INR of 2.8 is within the therapeutic range for clients on warfarin, so obtaining another blood sample is not necessary.
B. An INR of 2.8 indicates that the client is within the therapeutic range, so it is appropriate to give the next scheduled dose. However, monitoring for potential bleeding complications is a higher priority.
C. Monitoring for signs of bleeding is crucial because, while an INR of 2.8 is within the therapeutic range, it is still important to watch for any bleeding complications as part of routine care.
D. Notifying the healthcare provider is not immediately necessary unless there are signs of bleeding or other concerns, as an INR of 2.8 is typically within the acceptable range for therapeutic anticoagulation.

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Correct Answer is C

Explanation

A. Hard candy is a recommended way to manage dry mouth, a common side effect of many medications, including herbal supplements like St. John's wort.
B. Insomnia is a potential side effect of St. John's wort, so this information is correct.
C. St. John's wort can interact with oral contraceptives, reducing their effectiveness. Therefore, it is essential to use an additional form of contraception.
D. St. John's wort can increase sensitivity to sunlight, making sun protection important for clients.

A. Avoid hazardous activities until symptoms subside. B. Stop taking the medication immediately. C. Increase intake of fluids and high-protein foods. D. Obtain transportation to the emergency department.

Correct Answer is A

Explanation

A. Fatigue and dizziness are common side effects of baclofen, and the nurse should advise the client to avoid hazardous activities until these symptoms improve.
B. Stopping baclofen suddenly can lead to withdrawal symptoms and should not be done without consulting a healthcare provider.
C. Increasing fluid and protein intake is not specifically indicated for managing baclofen side effects.
D. Immediate transportation to the emergency department is unnecessary unless the client exhibits severe or worsening symptoms not related to typical side effects.

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