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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reducing fluid intake is not necessary for managing urinary retention with tamsulosin and could exacerbate symptoms.
B. Tamsulosin can cause orthostatic hypotension, so it is important to advise the client to stand and sit up slowly to prevent dizziness and falls.
C. The time of day the medication is taken is less critical compared to managing side effects related to blood pressure changes.
D. Tamsulosin is typically taken once daily, not on a twice-a-week schedule.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"},"G":{"answers":"C"}}
Explanation
1. Dizziness while sitting up: Non-therapeutic side effect
- Dizziness is a common side effect of minoxidil, often due to the vasodilatory effects, which can cause orthostatic hypotension.
2. Blood glucose 218 mg/dL: Unrelated finding
- Elevated blood glucose is unrelated to minoxidil administration and is more likely related to the client's diabetes.
3. Mouth dryness: Non-therapeutic side effect
- Dry mouth can be a side effect of minoxidil, though it is not a common one.
4. Blood pressure 162/111 mmHg: Therapeutic result
- The reduction in blood pressure from 203/166 mmHg to 162/111 mmHg is a therapeutic effect of minoxidil, which is used to lower blood pressure.
5. Heart rate 99: Non-therapeutic side effect
- Tachycardia can be a side effect of minoxidil, as it can lead to reflex tachycardia due to its vasodilatory effects.
6. Pain of 1 out of 10: Unrelated finding
- The reduction in pain is unrelated to the administration of minoxidil and is likely due to the ibuprofen given for pain management.
7. Urine output 600 mL: Unrelated finding
- Urine output is not directly related to the administration of minoxidil and is not typically affected by the drug.
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