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Total cholesterol: Total cholesterol showed only a modest decrease from 324 to 310 mg/dL and remains well above the target range. Gemfibrozil may slightly lower total cholesterol, but this is not the main marker of its effectiveness.

Low density lipoprotein (LDL): LDL decreased from 140 to 120 mg/dL, which is within the desired range. While this is a positive change, gemfibrozil is not primarily used for LDL reduction, making this an indirect and secondary effect.

High density lipoprotein (HDL): HDL dropped from 42 to 26 mg/dL, which is unfavorable. HDL should increase or stay stable during gemfibrozil therapy, so this change suggests a lack of benefit or even a negative response in that aspect of lipid regulation.

Protamine sulfate: Protamine sulfate is the antidote for heparin, not warfarin. It works by neutralizing the effects of heparin in cases of overdose or excessive anticoagulation. Since the client is taking warfarin, protamine would not address the elevated INR or the bleeding risk.

Heparin: Heparin is another anticoagulant and would further increase the client's bleeding risk. Administering heparin to a patient with an INR of 7.2 and visible hematomas could worsen the coagulopathy and potentially lead to life-threatening hemorrhage.

Vitamin C: Vitamin C is not involved in the coagulation cascade and has no role in reversing the effects of warfarin. While it supports vascular health generally, it does not correct an elevated INR or treat active bleeding in clients taking anticoagulants.

HMG CoA reductase inhibitor: atorvastatin: Statins like atorvastatin are contraindicated in pregnancy and in clients with active liver disease because they can cause teratogenic effects and hepatotoxicity. They work by inhibiting cholesterol synthesis in the liver, which places additional strain on hepatic function.

Vitamin B3: nicotinic acid: While niacin can lower cholesterol, it is poorly tolerated due to side effects such as flushing, hepatotoxicity, and glucose intolerance. It is not recommended for pregnant patients or those with liver disease due to its potential to worsen liver function.

Fenofibrate: gemfibrozil: Fibrates like gemfibrozil are used to reduce triglyceride levels but are associated with liver enzyme elevations and potential hepatotoxicity. They are not the first choice for pregnant patients or individuals with liver disease due to these risks.

Warfarin interferes with the production of prothrombin: Warfarin works by inhibiting vitamin K–dependent clotting factors, including prothrombin. While this is true, it does not fully explain the rationale for initiating warfarin while the client is still receiving heparin.

Heparin is more effective when administered with warfarin: Heparin and warfarin have different mechanisms of action and are not more effective when combined long-term. Heparin is used temporarily until warfarin reaches its therapeutic effect.

Warfarin potentiates the therapeutic action of heparin: Warfarin does not enhance the action of heparin. In fact, warfarin initially lowers protein C and S levels, which can temporarily increase clotting risk. The dual use is strictly for transitioning therapy, not to potentiate effects.

"St. John's Wort has not been demonstrated to help with your kind of symptoms": St. John’s Wort has been shown to have antidepressant effects, particularly in cases of mild to moderate depression. Dismissing its efficacy outright may be misleading and may overlook valid patient interest in alternative therapies.

"St. John's Wort might help, but you will still need your medications": This assumes the client will need to continue current medications without evaluating potential drug interactions. St. John’s Wort induces liver enzymes (especially CYP3A4), which can reduce the effectiveness of many prescription drugs, including antidepressants.

"St. John's Wort is a completely safe alternative that might reduce your need for medications”: St. John’s Wort can cause serious interactions with many prescription drugs, potentially leading to serotonin syndrome or reduced drug effectiveness, particularly with SSRIs or warfarin.

Hemoglobin level is 8.9 g/dL: This value is within the target range for clients receiving epoetin alfa, which is generally used to maintain hemoglobin between 10–11 g/dL. Although it is slightly low, it is not a critical finding that warrants immediate provider notification.

The client is afraid of subcutaneous injections: Fear of injections is an emotional concern and can be managed through education and reassurance. While it may affect compliance, it is not clinically urgent and does not require immediate provider involvement.

The client has a history of myocardial infarction: A prior MI is relevant but it is not an immediate contraindication for epoetin alfa unless the client is currently unstable or symptomatic. This history should be considered during long-term planning but is not an urgent finding.

Increases bile acid excretion in the liver: This mechanism describes how bile acid sequestrants like cholestyramine work. These drugs bind bile acids in the intestine, promoting their excretion and forcing the liver to use more cholesterol to produce new bile acids.

Decreases triglyceride synthesis in the liver: This is the primary action of fibrates such as gemfibrozil, which activate PPAR-alpha to decrease hepatic triglyceride production and increase lipolysis of VLDL.

Enhances the breakdown of low-density lipoprotein (LDL) cholesterol in the bloodstream: This mechanism aligns with statins, which upregulate LDL receptors on hepatocytes to increase LDL clearance.

Assessment of 24-hour urine: Cholestyramine does not primarily affect renal function or require monitoring of urinary output. It acts locally in the gastrointestinal tract to bind bile acids and is not absorbed systemically, making urine assessment a lower priority.

Auscultation of heart sounds: While important in a comprehensive assessment, heart sounds are not directly affected by cholestyramine therapy. Unless the client has a known cardiac condition, this is not the most relevant or immediate nursing assessment.

Palpation for peripheral edema in the lower extremities: Peripheral edema is not a common adverse effect of cholestyramine. While it could be relevant in clients with underlying heart or kidney issues, it is not a direct concern linked to this medication.