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
The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.
This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.
Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.
Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.
Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.
Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.
Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to
1.2 mg/dL.
Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.
The nurse should monitor these levels and report any abnormalities to the health care provider.
Correct Answer is D
Explanation
Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.
Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.
Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.
Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.
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