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 D
Explanation
a) Taking the medication to prevent asthma attacks is an appropriate use and does not require immediate intervention.
b) Using the rescue inhaler twice a month may indicate the need for further evaluation but does not pose an immediate threat.
c) Sleep disturbances are a known side effect of leukotriene blockers and may need attention, but it is not an urgent concern.
d) Expressing suicidal ideation and having a plan for self-harm is a critical situation that requires immediate intervention to ensure the client's safety and well-being.
Correct Answer is ["A","B"]
Explanation
A) Hold metformin 24 hours to 48 hours before the CT. This is correct because it reduces the chance of metformin accumulating in the blood and causing lactic acidosis when combined with the contrast dye.
B) Hold metformin 48 hours after the CT. This is also correct because it allows time for the contrast dye to be eliminated from the body before resuming metformin.
C) Double the metformin dose after the CT. This is incorrect and dangerous because it can cause hypoglycemia, low blood sugar, which can lead to confusion, seizures, coma, or death. D) Take metformin as scheduled the day of the CT. This is incorrect and risky because it can result in high levels of metformin in the blood when mixed with the contrast dye, increasing the likelihood of lactic acidosis.
E) Resume metformin at half dose after the CT. This is incorrect and unnecessary because there is no evidence that reducing the dose of metformin after a CT scan with contrast dye has any benefit or reduces any harm.
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