A patient on warfarin is found to have an INR of 5.0. What is the most appropriate action by the nurse?
Administer vitamin K per provider's orders.
Increase the dose of warfarin and monitor INR more frequently per provider's orders.
Discontinue warfarin and administer a dose of heparin per provider's orders.
Continue warfarin and monitor for any symptoms of bleeding per provider's orders.
The Correct Answer is A
A. An INR of 5.0 indicates a significantly increased risk of bleeding, and administering vitamin K is the appropriate antidote for reversing the effects of warfarin. This is a critical intervention to restore coagulation.
B. Increasing the dose of warfarin is inappropriate in this scenario because the INR is already elevated; it would further increase bleeding risk.
C. While heparin can be used for anticoagulation, it is not appropriate to administer it while the INR is dangerously high without reversing the warfarin first.
D. Continuing warfarin is unsafe at this INR level due to the high risk of bleeding; monitoring for symptoms without intervention is not adequate care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Confirming that the medication prescribed is the drug of choice for the specific microorganism is crucial in ensuring effective treatment, as the right drug will target the identified infection.
B. Teaching the client that significant adverse effects are expected and must be endured is not a supportive approach; the focus should be on managing and minimizing adverse effects rather than accepting them.
C. Administering antihistamines may not be relevant for all patients undergoing anti-infective treatment and is not a primary strategy for ensuring treatment success.
D. Monitoring for signs of arrhythmias or cardiac ischemia is not directly related to ensuring the success of anti-infective treatment; it may be necessary for certain medications but does not address the effectiveness of anti-infectives specifically.
Correct Answer is B
Explanation
A. Prothrombin time (PT) is used to monitor warfarin therapy, not heparin therapy.
B. Activated partial thromboplastin time (aPTT) is the primary laboratory test used to assess the effectiveness of heparin therapy, measuring the time it takes for blood to clot and ensuring therapeutic levels.
C. The International normalized ratio (INR) is also related to warfarin therapy rather than heparin.
D. Serum potassium level is not relevant for assessing heparin therapy but may be monitored for other reasons.
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