A client taking warfarin presents with bruises, dark tarry stools, and an international normalized ratio (INR) of 4.3. What is the nurse's action?
Explain to the client the nurse may ask the provider to order a test for leukemia.
Hold the warfarin and consult the provider regarding the next steps.
Give an ampule of Vitamin K, then call the physician to report client status.
Give the warfarin with a dark green salad and check the next stool for blood.
The Correct Answer is B
a. The symptoms described (bruises, dark tarry stools, elevated INR) are indicative of warfarin overdose or excessive anticoagulation, not leukemia.
b. This is the correct answer because holding the warfarin is necessary to prevent further bleeding complications, and consulting the provider is essential for guidance on the next steps.
c. Giving Vitamin K may be necessary in cases of severe bleeding due to warfarin, but it is not the initial action. Consulting the provider is the priority.
d. Giving warfarin with a dark green salad may exacerbate the situation and increase the risk of bleeding. Checking the next stool for blood does not address the immediate issue of anticoagulation excess.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale for A: Ibuprofen is generally considered safe for use while breastfeeding, as it passes into breast milk in small amounts that are not expected to harm the infant.
Rationale for B: Lithium can have serious effects on a breastfeeding infant, as it can cause lethargy and developmental issues. Its use is generally not recommended during breastfeeding.
Rationale for C: Methotrexate is contraindicated during breastfeeding due to its potential toxicity and harmful effects on the infant, including possible effects on growth and development.
Rationale for D: Nicotine is harmful to infants and can affect their development. Smoking or using nicotine products while breastfeeding is discouraged due to the associated risks.
Correct Answer is B
Explanation
A) Rhabdomyolysis is a serious condition characterized by the breakdown of skeletal muscle tissue and is not associated with the symptoms described.
B) Red man syndrome is an infusion reaction associated with the rapid infusion of vancomycin. Symptoms include flushing, rash, pruritus, urticaria, tachycardia, and hypotension.
C) Side effects are general and can include a range of symptoms. Red man syndrome is a specific reaction associated with vancomycin.
D) Stevens-Johnson syndrome is a severe skin reaction that involves blistering and peeling of the skin. It is not associated with the rapid infusion of vancomycin.
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