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 C

Explanation

A. Frequently assess the client’s blood pressure: While monitoring blood pressure is important, it is not as critical as monitoring the ECG in cases of diltiazem overdose. Diltiazem is a calcium channel blocker that can lead to significant cardiac effects.
B. Observe the client for signs of gastric irritation: This is relevant for some medications, but in the case of diltiazem overdose, the primary concern is the potential for severe cardiac effects rather than gastric irritation.
C. Monitor electrocardiogram (ECG) continuously: Diltiazem overdose can lead to serious cardiac arrhythmias, such as bradycardia, AV block, or other conduction disturbances. Continuous ECG monitoring is crucial to detect these potentially life-threatening complications.
D. Assess for changes in level of consciousness: While important, changes in level of consciousness are secondary to the immediate need to monitor cardiac function closely in the context of diltiazem overdose.

A. Nausea. B. Stridor. C. Headache. D. Pruritus.

Correct Answer is B

Explanation

A) 40-year-old female with frequent vaginal infections: Simvastatin is a medication used primarily to manage cholesterol levels and reduce the risk of cardiovascular diseases. Frequent vaginal infections are not directly related to cholesterol levels or cardiovascular risk. Therefore, this client is unlikely to benefit from education about simvastatin.
B) A 50-year-old male with a history of angina: Simvastatin is a statin medication prescribed to lower cholesterol levels and reduce the risk of cardiovascular events, such as heart attacks and strokes. Since angina is a symptom of coronary artery disease, a condition often related to high cholesterol levels, this client would benefit from education about simvastatin, which can help manage cholesterol and potentially reduce cardiovascular risk.
C) An 18-year-old pregnant female with type 1 diabetes mellitus: Statins, including simvastatin, are generally contraindicated during pregnancy due to potential risks to the developing fetus. Additionally, this client’s primary condition of type 1 diabetes mellitus would not typically be managed with simvastatin alone. Therefore, this client is not the target for simvastatin education.
D) A 75-year-old male with bone cancer: While simvastatin is used for managing cholesterol and preventing cardiovascular events, bone cancer is not directly related to cholesterol levels. The primary focus for this client would be managing cancer-related symptoms and treatments rather than cholesterol levels. Thus, this client would not benefit from education about simvastatin.

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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]

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Explanation

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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]