A client who is taking warfarin has an international normalized ratio (INR) of 0.8. Which question should a nurse ask to further evaluate the client?
Do your gums bleed when you brush your teeth?.
Are you taking the medication as prescribed?.
Have you noticed blood in your stools?.
Do you have any unusual bruising?.
The Correct Answer is B
Are you taking the medication as prescribed? This is because warfarin is a blood-thinning medication that affects the prothrombin time (PT) and the international normalized ratio (INR).
The PT measures how long it takes for blood to clot, and the INR is a calculation based on the PT that standardizes the results across different laboratories. A normal INR range is 0.8 to 1.1 for people who are not taking warfarin. People who take warfarin usually have a target INR range of 2 to 3, depending on their condition.
An INR of 0.8 means that the blood clots faster than normal, which increases the risk of blood clots and strokes.
This could indicate that the client is not taking enough warfarin or is taking other medications or foods that interfere with warfarin’s effect.
Choice A is wrong because bleeding gums are a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice C is wrong because blood in stools is also a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice D is wrong because unusual bruising is another sign of excessive bleeding, which could happen if the INR is too high, not too low.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.
Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.
They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.
Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.
Correct Answer is B
Explanation
This is because the resident is independent and sociable, and has the right to choose her own grooming preferences.
Serving her breakfast in her room will respect her autonomy and dignity, and prevent her from missing a meal.
Choice A is wrong because omitting her breakfast will deprive her of nutrition and hydration, and may cause health problems.
It will also violate her rights as a resident.
Choice C is wrong because getting her up early enough to be ready for breakfast will disrupt her sleep cycle and may cause fatigue or stress.
It will also impose the nurse’s values on the resident, and disregard her preferences.
Choice D is wrong because having her go to breakfast regardless of the state of her grooming will embarrass her and lower her self-esteem.
It will also disrespect her culture and values, and may affect her social interactions.
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