The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?

Give the next scheduled dose.

Obtain another blood sample.

Monitor for signs of bleeding.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is D

Choice A reason: Giving the next scheduled dose without further assessment is not advisable. An INR of 2.8 is within the therapeutic range for many conditions treated with warfarin, but it is important to ensure that the INR is stable and not trending higher, which could increase the risk of bleeding.

Choice B reason: Obtaining another blood sample might be necessary if there is suspicion of an error or if the INR is unexpectedly high or low. However, in this scenario, the INR is within the therapeutic range, so this action is not immediately necessary.

Choice C reason: Monitoring for signs of bleeding is always important for clients on warfarin, but it does not address the immediate need to communicate with the healthcare provider about the current INR level and any potential adjustments to the medication.

Choice D reason: Notifying the healthcare provider is the most appropriate action. The healthcare provider needs to be aware of the current INR level to make any necessary adjustments to the warfarin dosage and to provide further instructions on monitoring and follow-up.

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Correct Answer is D

Explanation

Choice A reason: A complete blood count (CBC) is not typically required before starting statin therapy. While a CBC can provide valuable information about a patient’s overall health, it does not specifically relate to the potential side effects or necessary monitoring for statin use. Statins primarily affect the liver, so monitoring liver function is more critical.

Choice B reason: Serum electrolytes are important for assessing overall metabolic and kidney function, but they are not directly related to the initiation of statin therapy. Statins do not typically affect electrolyte levels, so this test is not necessary before starting the medication.

Choice C reason: Capillary blood glucose levels are important for monitoring diabetes and blood sugar control. While statins can have an impact on blood glucose levels, this is not the primary concern when initiating therapy. Monitoring liver function is more directly related to the potential side effects of statins.

Choice D reason: Serum liver enzymes are crucial to review before starting statin therapy. Statins can cause liver enzyme elevations, indicating liver damage or dysfunction. Therefore, baseline liver enzyme levels should be obtained to monitor for any potential hepatotoxicity during treatment.

A. Place the patch on the client’s shoulder and leave both patches in place for 12 hours. B. Remove the patch and consult with the healthcare provider about the client’s pain resolution. C. Apply the new patch in a different location after removing the original patch. D. Administer an oral analgesic and evaluate its effectiveness before applying the new patch.

Correct Answer is C

Explanation

Choice A reason:

Placing the new patch on the client’s shoulder and leaving both patches in place for 12 hours is not recommended. Fentanyl patches are designed to be used one at a time, and overlapping patches can lead to an overdose due to excessive absorption of the medication1. The standard practice is to remove the old patch before applying a new one.

Choice B reason:

Removing the patch and consulting with the healthcare provider about the client’s pain resolution is a cautious approach. However, it is not necessary to consult the healthcare provider if the client denies pain and the patch is due for replacement. The nurse should follow the standard protocol for patch replacement.

Choice C reason:

Applying the new patch in a different location after removing the original patch is the correct action. This ensures that the medication is delivered effectively while preventing skin irritation and potential overdose. The new patch should be placed on a different area of intact skin to allow the previous site to recover.

Choice D reason:

Administering an oral analgesic and evaluating its effectiveness before applying the new patch is not appropriate in this scenario. The client is already receiving pain management through the transdermal patch, and additional oral analgesics are not necessary unless there is breakthrough pain. The focus should be on proper patch replacement

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The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication?

Correct Answer is D

Explanation

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. Which action should the nurse take?

Correct Answer is C

Explanation

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