A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

Hold the medication and notify the HCP

Administer the medication as ordered.

Prepare to administer vitamin K (AquaMephyton).

Assess the client for abnormal bleeding.

Fat embolism

Answer and Explanation

The Correct Answer is B

A. Hold the medication and notify the HCP: This is unnecessary. An INR of 2.7 is within the therapeutic range for a client with a mechanical valve replacement (2.5 to 3.5). No intervention is required.

B. Administer the medication as ordered: The INR of 2.7 is within the desired therapeutic range for clients on warfarin with mechanical valve replacements, so the nurse should proceed with the prescribed dose.

C. Prepare to administer vitamin K (AquaMephyton): Vitamin K is used to reverse the effects of warfarin if the INR is too high (usually greater than 5).

D. Assess the client for abnormal bleeding: While important, this is not the first action. The INR is within the therapeutic range, so the priority is to administer the medication.

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Correct Answer is C

Explanation

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.

B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.

C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.

D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.

A. Remind the client to look for food on the left side of the tray B. Provide a non-skid mat to alleviate plate movement. C. Encourage the client to use his right hand when feeding himself. D. Encourage the use of the wide grip utensils.

Correct Answer is A

Explanation

A. Remind the client to look for food on the left side of the tray: Homonymous hemianopsia is a condition in which a person loses vision in the same half of the visual field of each eye (in this case, the left visual field due to right-sided brain damage). The nurse should remind the client to look for food on the left side of the tray to help compensate for the visual deficit.

B. Provide a non-skid mat to alleviate plate movement. While a non-skid mat can help with plate stability, it does not address the visual field loss caused by homonymous hemianopsia.

C. Encourage the client to use his right hand when feeding himself. There is no specific benefit to using the right hand when a client is experiencing a visual deficit in the left visual field. Instead, compensating for the visual field loss is the priority.

D. Encourage the use of the wide grip utensils. Wide grip utensils are helpful for clients with limited hand mobility but will not address the specific visual impairment caused by homonymous hemianopsia.

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A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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