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
a) Spironolactone is a potassium-sparing diuretic, and the use of salt substitutes, which often contain potassium chloride, can lead to increased potassium levels, posing a risk of hyperkalemia.
b) Continuing medication even when feeling well is generally advised, especially for chronic conditions. Discontinuing medication without medical guidance is not recommended. c) While a healthy diet is important, this option does not specifically address the unique considerations related to spironolactone use.
d) Checking the pulse is not directly related to self-care in terms of the medication's side effects or interactions.
Correct Answer is B
Explanation
a) The statement about not taking a scheduled-dose preparation of acetaminophen with opioid analgesics is unrelated to the client's question about alcohol consumption.
b) Excessive alcohol intake increases the risk of acetaminophen-induced liver damage. The recommended maximum dose is 3 grams per day to minimize the risk of hepatotoxicity.
c) The recommendation of not exceeding 2 gm of acetaminophen a day is conservative, but the commonly accepted maximum is 3 grams per day.
d) While the general guideline is not to exceed 4 grams of acetaminophen per day for the general population, individuals with alcohol consumption may be more susceptible to liver damage, so a lower limit is often advised.
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