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.
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Related Questions
Correct Answer is B
Explanation
Gently pull the auricle up and back before instilling the drops. This technique straightens the auditory canal and allows the drops to reach the eardrum.
It also prevents contamination of the ear canal by the finger.
Choice A is wrong because pulling the auditory canal down and toward the front is the proper method for children, not adults.
This technique is used for children because their auditory canal is shorter and more curved than adults.
Choice C is wrong because lowering the head and taking a deep breath during the instillation has no effect on the administration of otic drops.
It may also cause discomfort or dizziness for the client.
Choice D is wrong because wearing sterile gloves and inserting one finger in the canal is unnecessary and potentially harmful.
It may introduce bacteria or damage the ear canal or eardrum.
Correct Answer is C
Explanation
What has it been like for you since your wife died? This statement shows empathy and invites the client to share his feelings and experiences.
It also acknowledges the client’s loss and validates his grief.
Choice A. Tell me how your wife died.
This statement is too intrusive and may cause the client to feel uncomfortable or defensive. It also focuses on the past event rather than the present situation.
Choice B. Have you considered attending a grief group? This statement is too premature and may imply that the nurse is trying to solve the client’s problem or dismiss his feelings.
It also assumes that the client needs or wants a grief group.
Choice D. You have wonderful children and grandchildren who are very supportive.
This statement is too superficial and may minimize the client’s grief or make him feel guilty. It also shifts the attention away from the client and his wife.
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