The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement?

Reference Range:

International 1 normalized ratio (INR) [INR: 0.8 to 1.1]

Administer the scheduled dose.

Discontinue the warfarin schedule.

Withhold warfarin for 24 hours

Obtain another INR analysis immediately.

Answer and Explanation

The Correct Answer is C

A) Administer the scheduled dose: Administering the scheduled dose of warfarin when the INR is 5.0 is not appropriate because this INR level is significantly elevated, indicating a high risk of bleeding. Warfarin dosing should be adjusted based on INR levels to prevent complications such as excessive bleeding.
B) Discontinue the warfarin schedule: Completely discontinuing warfarin may not be necessary unless there are additional factors or signs of bleeding. It is essential to take appropriate action based on the INR level, but discontinuation should be guided by further evaluation and healthcare provider recommendations.
C) Withhold warfarin for 24 hours: Withholding the dose of warfarin is the correct action when faced with an elevated INR of 5.0. This intervention is crucial to prevent potential bleeding complications while waiting for further evaluation and guidance from the healthcare provider regarding additional management, such as administration of vitamin K or other reversal agents.

D) Obtain another INR analysis immediately: While obtaining another INR analysis can be helpful in monitoring trends, it is not the immediate priority if the INR is already 5.0. The primary action should be to withhold the dose and consult with the healthcare provider to determine the appropriate next steps for managing the elevated INR and ensuring patient safety.

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Correct Answer is B

Explanation

A. Accommodation: Mydriatic eye drops cause dilation of the pupils, but they do not directly affect the eye's ability to accommodate or focus on near objects. Therefore, accommodation may still be functional, though it can be affected indirectly due to the dilated pupils.
B. Pupillary constriction: Mydriatic eye drops are designed to dilate the pupils, so they inhibit or prevent pupillary constriction. This is the primary purpose of these drops, so pupillary constriction will not occur during their therapeutic effect.
C. Refraction: Refraction refers to the bending of light as it passes through the eye to focus on the retina. This function is generally maintained even when mydriatic drops are used, though changes in pupil size can affect the amount of light entering the eye.
D. Eye convergence: Convergence involves the inward movement of both eyes toward each other to maintain single binocular vision when focusing on a close object. While mydriatic drops primarily affect pupil dilation, convergence can still occur, though it may be affected by the degree of dilation.

A. Low-density lipoprotein (LDL) B. Prothrombin time (PT). C. Creatine phosphokinase (CK) D. High-density lipoprotein (HDL).

Correct Answer is D

Explanation

A. Low-density lipoprotein (LDL): Atorvastatin's primary effect is to decrease LDL cholesterol levels. A decrease in LDL levels would indicate the medication is working as intended, not an increase.
B. Prothrombin time (PT): PT is a measure of blood clotting, which is not directly affected by atorvastatin. This value is more relevant for monitoring anticoagulant therapy.

C. Creatine phosphokinase (CK): CK levels can be used to monitor for muscle damage or side effects related to statin use. An increase in CK levels would suggest muscle damage, not the effectiveness of the statin.
D. High-density lipoprotein (HDL): Atorvastatin is a statin medication used to lower cholesterol levels, particularly low-density lipoprotein (LDL) cholesterol, which is a key target in reducing the risk of coronary artery disease (CAD). While the primary goal of atorvastatin is to lower LDL cholesterol, an increase in HDL cholesterol (often termed "good" cholesterol) is also desirable as it can help reduce the risk of CAD. Therefore, an increase in HDL is a positive indicator that the medication is having a beneficial effect.

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The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement? Reference Range: International 1 normalized ratio (INR) [INR: 0.8 to 1.1]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the eyes of a client who just received mydriatic eye drops. Which physiological function of the eye will not respond during the therapuetic period after administration of the eye drops?

Correct Answer is B

Explanation

An increase in which serum lab value indicates to the nurse that a prescription for atorvastatin is having the desired effect for a client at risk for coronary artery disease?

Correct Answer is D

Explanation

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A male client reports to the nurse that he is experiencing gastrointestinal (GI) distress from a high dose of a corticosteroid and is planning to stop taking the medication. In response to the client's statement, which nursing action is most important for the nurse to Implement?

The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement?

Reference Range:

International 1 normalized ratio (INR) [INR: 0.8 to 1.1]