A client with a deep vein thrombosis has been receiving warfarin sodium 2.5 mg PO daily. The client's International Normalized Ratio (INR) is 5.0. The nurse is aware that the medication dose needs to be:
increased.
given as prescribed.
cut in half.
held.
The Correct Answer is D
A. An INR of 5.0 indicates that the blood is significantly thinner than the therapeutic range (typically 2.0 to 3.0 for DVT treatment). Increasing the dose of warfarin would further increase the risk of bleeding.
B. Continuing with the prescribed dose of 2.5 mg is not appropriate at this time. The INR is above the safe therapeutic range, indicating a need for adjustment, not maintenance of the current dose.
C. While reducing the dose may be necessary, cutting it in half may not adequately address the high INR. The more appropriate action would involve holding the dose or significantly adjusting it based on the INR and clinical guidelines.
D. An INR of 5.0 is a critical value that suggests the client is at an increased risk of bleeding. The appropriate action in this case is to hold the warfarin dose and notify the healthcare provider for further evaluation and management. Depending on clinical protocols, the provider may recommend administering vitamin K to reverse the effects of warfarin, especially if there are signs of bleeding or if the INR is critically high.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Infections, including urinary tract infections, can increase insulin resistance and elevate blood glucose levels, potentially leading to DKA. The stress response from infection can also increase cortisol levels, further contributing to hyperglycemia.
B. Decreased caloric intake can lead to inadequate insulin levels relative to the body’s needs. In Type 1 diabetes, if insulin is not sufficient to metabolize glucose (due to low intake or other reasons), the body may resort to fat metabolism, leading to the production of ketones and the development of DKA.
C. While exercise can affect blood glucose levels, it typically lowers them and is not a direct cause of DKA. In fact, moderate aerobic exercise is usually encouraged for managing diabetes. However, if blood glucose levels are already high before exercise, it may exacerbate the situation, but aerobic exercise itself is not a cause of DKA.
D. Clogged tubing can prevent insulin delivery, leading to insufficient insulin levels. This lack of insulin can result in elevated blood glucose levels and, ultimately, the risk of DKA if not addressed.
E. Not taking enough insulin is a primary cause of DKA in Type 1 diabetes. Without adequate insulin, the body cannot utilize glucose properly, leading to increased fat metabolism and the production of ketones, which can cause DKA.
Correct Answer is D
Explanation
A. This is a symptom of urinary tract infection, not renal colic.
B. This indicates kidney damage, which may occur as a complication of untreated kidney stones, but it's not a typical symptom of renal colic itself.
C. This is not a symptom of renal colic.
D. This is a classic symptom of renal colic, which is caused by the passage of a kidney stone through the ureter. The pain is often described as excruciating and can radiate to the groin or testicle.
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