The nurse is caring for a patient with atrial fibrillation who has been prescribed warfarin (Coumadin). The patient’s INR level is 3.5, which is above therapeutic range. What action should the nurse take?
Administer vitamin K as ordered by physician
Administer heparin as ordered by physician
Administer warfarin as ordered by physician
Hold warfarin and notify physician.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Digoxin (Lanoxin) is a cardiac glycoside that is used to treat atrial fibrillation and heart failure.
It works by increasing the force of cardiac contraction and slowing down the heart rate.
However, digoxin can also cause toxicity, which can lead to life-threatening arrhythmias.
One of the risk factors for digoxin toxicity is hypokalemia, or low serum potassium level.
Potassium is an electrolyte that is essential for normal cardiac function and conduction.When the serum potassium level is low, digoxin binds more strongly to the cardiac cells and increases its effects, which can result in bradycardia, heart block, or ventricular tachycardia.
Therefore, the nurse should monitor the serum potassium level to evaluate the therapeutic effectiveness and safety of digoxin therapy.
Choice B) Serum sodium level is wrong because sodium is not directly related to digoxin action or toxicity.
Sodium is another electrolyte that is important for fluid balance and blood pressure regulation.However, sodium does not affect the binding of digoxin to the cardiac cells or its effects on the heart rate and contractility.
Therefore, the nurse does not need to monitor the serum sodium level to evaluate digoxin therapy.
Choice C) Serum magnesium level is wrong because magnesium is not directly related to digoxin action or toxicity.
Magnesium is another electrolyte that is involved in many enzymatic reactions and neuromuscular function.However, magnesium does not affect the binding of digoxin to the cardiac cells or its effects on the heart rate and contractility.
Therefore, the nurse does not need to monitor the serum magnesium level to evaluate digoxin therapy.
Choice D) Serum calcium level is wrong because calcium is not directly related to digoxin action or toxicity.
Calcium is another electrolyte that is essential for bone health and muscle contraction.However, calcium does not affect the binding of digoxin to the cardiac cells or its effects on the heart rate and contractility.
Therefore, the nurse does not need to monitor the serum calcium level to evaluate digoxin therapy.
The normal range for serum potassium level is 3.5-5.0 mEq
Correct Answer is A
Explanation
The nurse should monitor the client’s serum potassium level closely because furosemide is a loop diuretic that can cause hypokalemia, which increases the risk of cardiac arrhythmias and digitalis toxicity. The nurse should also monitor the client’s fluid status, blood pressure, and renal function.
Choice B is wrong because Serum calcium is wrong because furosemide does not affect calcium levels significantly. Calcium levels are more likely to be affected by thiazide diuretics, which can cause hypercalcemia.
Choice C is wrong because Serum albumin is wrong because furosemide does not affect albumin levels significantly. Albumin levels are more likely to be affected by liver disease, malnutrition, or nephrotic syndrome.
Choice D is wrong because Serum glucose is wrong because furosemide does not affect glucose levels significantly. Glucose levels are more likely to be affected by diabetes mellitus, corticosteroids, or stress.
Normal ranges for the laboratory values are:
• Serum potassium: 3.5-5.0 mEq/L
• Serum calcium: 8.5-10.5 mg/dL
• Serum albumin: 3.5-5.0 g/dL
• Serum glucose: 70-110 mg/dL
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