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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Free Nursing Study Resources

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.

A. Peripheral edema B. Potassium 2.9 C. Urine output 280 ml D. Heart rate 79 E. Intracranial pressure 11mmHg F. Oxygen saturation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

1. Peripheral edema: Non-therapeutic side effect

- Mannitol is an osmotic diuretic that can cause fluid shifts leading to peripheral edema, which is an unintended side effect.

2. Potassium 2.9: Non-therapeutic side effect

- Hypokalemia (low potassium) is a potential side effect of mannitol due to increased urinary excretion of electrolytes.

3. Urine output 280 mL: Therapeutic result

- Mannitol increases urine output as it promotes diuresis, which is the intended therapeutic effect.

4. Heart rate 79: Unrelated finding

- The heart rate of 79 beats/minute is within normal limits and is not directly related to the administration of mannitol.

5. Intracranial pressure 11 mmHg: Therapeutic result

- The decrease in intracranial pressure from 24 mmHg to 11 mmHg is a desired therapeutic outcome of mannitol, as it helps reduce cerebral edema.

6. Oxygen saturation: Unrelated finding

- The oxygen saturation of 99% is within normal limits and is not directly related to the administration of mannitol.

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Body system	Potential nursing intervention
Cardiovascular	Monitor vital signs continuously Provide warmth Echocardiogram Defibrillator at bedside
Immunological	Administer steroid Assess rash IV fluids Administer antihistamine
Respiratory	Assess lung sounds Pain medication Provide calm environment Chest x-ray

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?

Correct Answer is A

Explanation

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

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