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
Explanation
This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.
This is a serious condition that requires immediate medical attention.
Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.
It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.
Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.
It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.
Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.
It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.
Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.
Correct Answer is A
Explanation
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
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