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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

a) Checking the pulse is not directly related to the use of inhaled steroids. It's important for assessing certain medications, but not for inhaled steroids.

b) Taking the medication before eating is not a specific recommendation for inhaled steroids. It's more important to follow the specific instructions provided for the particular medication.

c) Limiting caffeine intake is not a standard recommendation for the use of inhaled steroids. This action is not directly related to potential complications with these medications.

d) Rinsing the mouth after inhaling the medicine is crucial to prevent the development of oral candidiasis, a common complication associated with inhaled steroids.

A. Instruct the client to notify the nurse if they have any tingling in their toes. B. Interpret the peak and trough levels. C. Assess the client's urine output. D. Consult the provider about the need for a less nephrotoxic medication.

Correct Answer is B

Explanation

a) Tingling in the toes may be indicative of peripheral neuropathy but is not specifically related to elevated BUN and serum creatinine levels.

b) Elevated BUN and serum creatinine levels suggest potential renal impairment, and interpreting peak and trough levels of vancomycin is essential to assess the drug's impact on renal function.

c) Assessing urine output is important in evaluating renal function, but the specific action related to the elevated BUN and creatinine levels is to interpret vancomycin levels.

d) Consulting the provider about the need for a less nephrotoxic medication may be a consideration, but understanding the impact of vancomycin on renal function through peak and trough levels is a crucial initial step.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has asthma the appropriate use of inhaled fluticasone. What advice should the nurse give to help the client avoid complications with the use of inhaled steroids?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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