A nurse is caring for a client who has been taking warfarin and has an international normalized ratio (INR) time of 5. Which of the following medications should the nurse anticipate the provider to prescribe?

Ferrous sulfate

Heparin

Prednisone

Vitamin K

Answer and Explanation

The Correct Answer is D

A. Ferrous sulfate: Ferrous sulfate is an iron supplement used to treat or prevent low blood levels of iron (such as those caused by anemia or pregnancy). It is not used to treat high INR levels.

B. Heparin: Heparin is an anticoagulant, or blood thinner, that prevents the formation of blood clots. It would not be used to treat a high INR level, as it could potentially increase the INR even further.

C. Prednisone: Prednisone is a corticosteroid that reduces inflammation in the body. It is not used to treat high INR levels.

D. Vitamin K: This is correct. Vitamin K is used to help blood clot and is given to patients who have a high INR level to reduce the risk of bleeding. Warfarin works by blocking the effects of vitamin K, so giving vitamin K can help reverse the effects of warfarin and lower the INR.

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Correct Answer is B

Explanation

(A) Re-collection of data: Re-collection of data is not the next step after planning. It might be done as part of the evaluation step or if there are significant changes in the client’s condition.

(B) Implementation: This is the most appropriate answer. After the planning step of the nursing process, the nurse moves on to the implementation step. This is where the nurse executes the interventions that were identified during the planning step.

(C) Data Collection: Data collection is typically the first step in the nursing process, where the nurse gathers information about the client’s health status. It is not the next step after planning.

(D) Evaluation: Evaluation is the final step of the nursing process. It involves assessing the client’s response to the nursing interventions and determining whether the client’s goals have been met. It is not the next step after planning.

A. Limit the client's visitors to one at a time. B. Avoid touching the client. C. Continue to talk to the client as if they are alive D. Whisper when talking in the client's room.

Correct Answer is C

Explanation

(A) Limit the client’s visitors to one at a time: While it’s important to maintain a peaceful environment for the client, limiting visitors may not be necessary unless the client’s condition is being negatively affected by too many visitors or if there are restrictions due to infection control.

(B) Avoid touching the client: Touch can be a powerful form of communication, especially when a client is unresponsive. Gentle touch can convey caring and presence, so avoiding touch is not typically recommended unless there’s a specific reason to do so (like if the client is in pain).

(C) Continue to talk to the client as if they are alive: This is the most appropriate answer. Even if a client is unresponsive, they may still be able to hear and understand. Continuing to talk to the client can provide comfort and reassurance.

(D) Whisper when talking in the client’s room: Whispering is not necessary and can even be confusing or distressing for the client. It’s better to speak in a normal, calm, and reassuring voice.

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A nurse is caring for a client who has been taking warfarin and has an international normalized ratio (INR) time of 5. Which of the following medications should the nurse anticipate the provider to prescribe?

Nursing Test Bank

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