A nurse is caring for a client who has an indwelling urinary catheter.

The nurse notes that sediment is present in the urine.

Which of the following actions should the nurse take to obtain a sterile urine specimen?

The correct answer is b. Remove the device from the room.

Choice A rationale:

• Reporting the defect to the equipment maintenance staff is essential,but it's not the immediate priority.The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
• Delaying the removal of the device could lead to electrical shock,fire,or other serious consequences.
• Therefore,removing the device from the room takes precedence over reporting the defect.

Choice B rationale:

• Removing the device from the room is the most appropriate first action because it:
  • Eliminates the immediate safety hazard.
  • Prevents potential harm to the client and others.
  • Protects the device from further damage.
  • Ensures the safety of the environment.
  • Demonstrates the nurse's prioritization of patient safety.

Choice C rationale:

• Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
• However,it's not the first action because it doesn't address the immediate safety concern.
• The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.

Choice D rationale:

• Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
• However,it's not relevant to the immediate safety issue of the frayed cord.
• The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
• The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.

The correct answer is choice A. INR.

Warfarin is a vitamin K antagonist that inhibits the synthesis of factors II, VII, IX, and X in the liver.

These factors are part of the extrinsic and common pathways of coagulation, which are measured by the prothrombin time (PT) and the international normalized ratio (INR).

The INR is a standardized way of reporting the PT that accounts for the variability of different reagents and instruments.

The INR is used to monitor the therapeutic effect of warfarin and to adjust the dose accordingly.

The target INR range depends on the indication for warfarin, but it is usually between 2 and 3 for most conditions.

Choice B is wrong because fibrinogen level is not affected by warfarin.

Fibrinogen is a precursor of fibrin, which forms the final step of the coagulation cascade.

Fibrinogen level can be decreased in conditions such as disseminated intravascular coagulation (DIC), liver disease, or severe bleeding. Choice C is wrong because aPTT is not affected by warfarin.

aPTT measures the intrinsic and common pathways of coagulation, which are mainly dependent on factors VIII, IX, XI, and XII.

These factors are not inhibited by warfarin.

aPTT is used to monitor the effect of heparin, a direct antithrombin agent that inhibits thrombin and factor Xa.

Choice D is wrong because platelet count is not affected by warfarin.

Platelets are cell fragments that adhere to damaged blood vessels and form aggregates to initiate hemostasis.

Platelet count can be decreased in conditions such as immune thrombocytopenia (ITP), heparin-induced thrombocytopenia (HIT), or bone marrow suppression.

Normal ranges:

• INR: 0.8-1.2
• Fibrinogen: 200-400 mg/dL
• aPTT: 25-35 seconds
• Platelet count: 150-450 x 10^9/L References: