A patient is prescribed Coumadin (warfarin) for anticoagulation therapy.

The patient's INR (International Normalized Ratio) is 2.5 and the desired range is 2-3. The medication order is for Coumadin 7.5 mg daily at 6 pm and comes in 5 mg tablets.

How many tablets should the nurse administer?

The correct answer is Assess the client’s airway, Apply high-flow oxygen, Administer IV epinephrine, Call the emergency response team.

Step 1 is: Assess the client’s airway.

Step 2 is: Apply high-flow oxygen.

Step 3 is: Administer IV epinephrine.

Step 4 is: Call the emergency response team.

Choice A rationale

Assessing for increased calcium levels is not directly related to malnutrition in cancer patients. Malnutrition in cancer often involves deficits in various nutrients, and while electrolyte imbalances can occur, increased calcium is not a primary or universal indicator of malnutrition itself. It might be related to cancer processes like bone metastasis, but not the malnutrition specifically.

Choice B rationale

Encouraging mouth care before and after meals is crucial because it promotes oral hygiene and can improve the client's appetite and taste perception. Malnutrition often leads to oral discomfort, stomatitis, or altered taste, making food unappealing. Proper mouth care can alleviate these issues, thereby enhancing the client's willingness to eat and improving nutrient intake.

Choice C rationale

Advising the client to keep a food diary helps in accurately assessing their dietary intake. This objective record allows the nurse and other healthcare providers to identify patterns of consumption, quantify caloric and nutrient deficits, and tailor nutritional interventions more effectively. It provides valuable data for personalized care planning to address malnutrition.

Choice D rationale

Monitoring the client for changes in mental status is important because severe malnutrition, particularly deficiencies in certain vitamins (e.g., thiamine, B12) or significant electrolyte imbalances, can lead to neurological impairments. Altered mental status could indicate worsening nutritional status or complications requiring immediate intervention to prevent further deterioration.

Choice E rationale

Instructing the client to drink extra fluids between meals helps prevent early satiety that can occur if fluids are consumed with meals, which can reduce food intake. By consuming fluids between meals, the client can maintain hydration without compromising their ability to consume sufficient solid food, thus maximizing caloric and nutrient intake for malnutrition.