After receiving the third dose of a new oral anticoagulant prescription, an older client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

Obtain a soft bristle toothbrush for client.

Provide a PRN nonsteroidal anti-inflammatory (NSAID) for gum discomfort.

Review most recent coagulation lab values.

Report findings to healthcare provider.

Complete a medication variance report.

Answer and Explanation

Correct Answer : A,C,D

A) Obtain a soft bristle toothbrush for the client:
This is an appropriate action because bleeding and tender gums can indicate oral bleeding, which may be exacerbated by the use of a standard toothbrush. Switching to a soft bristle toothbrush can help minimize trauma to the gums and reduce bleeding.

B) Provide a PRN nonsteroidal anti-inflammatory drug (NSAID) for gum discomfort:
Administering NSAIDs in this situation is not recommended. NSAIDs can further increase the risk of bleeding due to their antiplatelet effects. Therefore, providing an NSAID could exacerbate the client’s bleeding symptoms.

C) Review most recent coagulation lab values:
This is a crucial action to assess the client’s coagulation status and determine if the bleeding and bruising are related to anticoagulant therapy. Reviewing coagulation lab values, such as prothrombin time (PT) and international normalized ratio (INR), can provide important information about the client’s clotting function and guide further management.

D) Report findings to the healthcare provider:
This is essential to ensure timely evaluation and management of the client’s symptoms. Bleeding and bruising after anticoagulant therapy may indicate an increased risk of bleeding complications, and the healthcare provider needs to be informed promptly for further assessment and possible adjustment of the anticoagulant regimen.

E) Complete a medication variance report:
While documenting the client’s symptoms and actions taken is important for quality assurance and tracking adverse events, completing a medication variance report may not be the immediate priority in this situation. The focus should be on assessing the client’s condition, managing symptoms, and communicating with the healthcare provider for appropriate intervention

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Correct Answer is A

Explanation

A) Advise the client to move slowly and cautiously when rising and walking: This intervention is essential because baclofen, a muscle relaxant, can cause dizziness, drowsiness, and muscle weakness as side effects. Instructing the client to move slowly and cautiously can help prevent falls and injuries due to these potential side effects.
B) Monitor intake and output every 8 hours: Monitoring intake and output is not directly related to the administration of baclofen. While it is essential to monitor fluid balance in some situations, it is not specifically indicated in this case.
C) Ensure the client knows to stop baclofen before using other antispasmodics: While it is important to avoid concurrent use of multiple antispasmodic medications without proper medical supervision, stopping baclofen abruptly without medical guidance can lead to withdrawal symptoms. Therefore, this intervention is not appropriate without further clarification from the healthcare provider.
D) Evaluate muscle strength every 4 hours: While monitoring muscle strength is essential for clients receiving muscle relaxants, such as baclofen, evaluating it every 4 hours may not be necessary unless there are specific concerns or as directed by the healthcare provider. Monitoring for signs of muscle weakness or adverse effects should be ongoing but may not require such frequent assessments.

A. Sodium level 140 mEq/L (140 mmol/L). B. Total calcium level 12 mEq/L (3 mmol/L). C. Total bilirubin 4 mg/dL (68.4 μmol/L). D. Serum glucose 170 mg/dL (9.4 mmol/L).

Correct Answer is B

Explanation

A) Sodium level 140 mEq/L (140 mmol/L):
The sodium level within the reference range does not indicate a vitamin D overdose. Sodium levels are typically not affected by vitamin D overdose.

B) Total calcium level 12 mg/dL (3 mmol/L):
This finding suggests a possible vitamin D overdose. Vitamin D plays a crucial role in calcium absorption from the intestines. Excessive vitamin D intake can lead to increased calcium absorption, resulting in hypercalcemia. Elevated calcium levels can lead to various symptoms such as nausea, vomiting, weakness, and confusion. Monitoring calcium levels is essential in individuals with suspected vitamin D overdose.

C) Total bilirubin 4 mg/dL (68.4 μmol/L):
Elevated bilirubin levels typically indicate liver dysfunction or hemolysis. It is not directly related to vitamin D overdose.

D) Serum glucose 170 mg/dL (9.4 mmol/L):
Elevated glucose levels suggest hyperglycemia, which can occur due to various factors such as diabetes mellitus or stress response. It is not directly related to vitamin D overdose.

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After receiving the third dose of a new oral anticoagulant prescription, an older client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

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