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. Taking an antiemetic medication: This information is not directly relevant before administering misoprostol. Misoprostol does not typically interact with antiemetic medications in a way that would change the administration plan.
B. Allergy to aspirin: While important to know for general medication safety, misoprostol's primary concern is its potential effects on pregnancy rather than an allergy to aspirin.
C. Currently pregnant: Misoprostol is contraindicated in pregnancy due to its potential to induce uterine contractions and cause miscarriage. It is crucial to confirm that the patient is not pregnant before administering this medication.
D. History of glaucoma: While important for other medications, a history of glaucoma is not a primary concern when administering misoprostol.

A. Protect the skin from sunlight while taking the drug. B. Take with orange juice to enhance gastrointestinal (GI) absorption. C. Return to the clinic weekly to obtain serum drug levels. D. Take with milk or antacids to prevent gastrointestinal (GI) irritation.

Correct Answer is A

Explanation

A) Protect the skin from sunlight while taking the drug: Tetracycline is known to increase sensitivity to sunlight, leading to a higher risk of sunburn and skin reactions. Advising clients to protect their skin from sun exposure and to use sunscreen is essential to prevent these adverse effects. This precaution helps mitigate the risk of photosensitivity reactions that are commonly associated with tetracycline use.
B) Take with orange juice to enhance gastrointestinal (GI) absorption: Tetracycline should not be taken with dairy products or antacids, as they can bind with the medication and reduce its absorption. While orange juice can enhance absorption, this is not a standard recommendation for tetracycline. Instead, it is generally advised to take tetracycline with water and avoid substances that could interfere with its absorption.
C) Return to the clinic weekly to obtain serum drug levels: Tetracycline typically does not require regular monitoring of serum drug levels, as it does not have a narrow therapeutic index like some other drugs. Instead, patients are generally advised on how to manage side effects and adherence to the medication regimen, rather than frequent clinic visits for drug level monitoring.
D) Take with milk or antacids to prevent gastrointestinal (GI) irritation: Milk and antacids should be avoided when taking tetracycline because they can bind to the medication and significantly reduce its effectiveness. This instruction could lead to decreased therapeutic efficacy and should be avoided. Tetracycline should be taken on an empty stomach to ensure optimal absorption, avoiding interactions with these substances.

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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

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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]