The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement?

Reference Range:

International 1 normalized ratio (INR) [INR: 0.8 to 1.1]

Administer the scheduled dose.

Discontinue the warfarin schedule.

Withhold warfarin for 24 hours

Obtain another INR analysis immediately.

Answer and Explanation

The Correct Answer is C

A) Administer the scheduled dose: Administering the scheduled dose of warfarin when the INR is 5.0 is not appropriate because this INR level is significantly elevated, indicating a high risk of bleeding. Warfarin dosing should be adjusted based on INR levels to prevent complications such as excessive bleeding.
B) Discontinue the warfarin schedule: Completely discontinuing warfarin may not be necessary unless there are additional factors or signs of bleeding. It is essential to take appropriate action based on the INR level, but discontinuation should be guided by further evaluation and healthcare provider recommendations.
C) Withhold warfarin for 24 hours: Withholding the dose of warfarin is the correct action when faced with an elevated INR of 5.0. This intervention is crucial to prevent potential bleeding complications while waiting for further evaluation and guidance from the healthcare provider regarding additional management, such as administration of vitamin K or other reversal agents.

D) Obtain another INR analysis immediately: While obtaining another INR analysis can be helpful in monitoring trends, it is not the immediate priority if the INR is already 5.0. The primary action should be to withhold the dose and consult with the healthcare provider to determine the appropriate next steps for managing the elevated INR and ensuring patient safety.

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Correct Answer is B

Explanation

A. Obtain a platelet count weekly: Regular monitoring of platelet counts is important for clients on methotrexate due to the risk of bone marrow suppression and potential thrombocytopenia. This instruction is appropriate and necessary.
B. Take the medication during pregnancy: Methotrexate is contraindicated during pregnancy due to its teratogenic effects and potential to cause fetal harm. It is crucial for clients to avoid using methotrexate while pregnant or planning to become pregnant.
C. Use folic acid to protect the liver: While folic acid is often used to help reduce the side effects of methotrexate, particularly its gastrointestinal effects and potential for liver toxicity, it is not used to "protect the liver" per se. The correct approach is to use folic acid as directed by a healthcare provider, often to mitigate some of the side effects of methotrexate.
D. Store the medication at room temperature: Methotrexate should be stored according to the manufacturer's instructions, which usually involve keeping it at room temperature. This information is correct and does not require additional instruction.

A. Administer sucralfate once a day, preferably at bedtime. B. Monitor for electrolyte imbalance. C. Assess for secondary Candida infection. D. Give sucralfate on an empty stomach.

Correct Answer is D

Explanation

A. Administer sucralfate once a day, preferably at bedtime: Sucralfate is typically administered multiple times a day, not just once. It is commonly given in divided doses, often four times a day, to ensure adequate coverage and effectiveness. Administering it at bedtime alone would not provide consistent therapeutic effects.
B. Monitor for electrolyte imbalance: Sucralfate is not known to cause significant electrolyte imbalances. It works locally in the gastrointestinal tract and does not usually affect electrolyte levels, so monitoring for electrolyte imbalances is not a primary concern with this medication.
C. Assess for secondary Candida infection: While sucralfate may affect the gastrointestinal flora, secondary Candida infections are not a common side effect. Sucralfate is not an antibiotic and does not typically lead to fungal infections.
D. Give sucralfate on an empty stomach: Sucralfate should be administered on an empty stomach, ideally 1 hour before meals or 2 hours after meals. This allows the medication to properly adhere to the ulcer site and form a protective barrier, enhancing its effectiveness in treating peptic ulcers.

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The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement? Reference Range: International 1 normalized ratio (INR) [INR: 0.8 to 1.1]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for methotrexate. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is B

Explanation

The nurse is planning to administer sucralfate to a client with peptic ulcer disease. Which action should the nurse indude in this patient's plan of care?

Correct Answer is D

Explanation

The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement? Reference Range: International 1 normalized ratio (INR) [INR: 0.8 to 1.1]

The nurse administers risedronate to a client with osteoporosis at 0700. The client asks for a glass of milk to drink with the medication. Which action should the nurse take?

Levothyroxine sodium is prescribed for a client with hypothyroidism. The nurse should instruct the client to report which symptom because it indicates that the client is taking too much levothyroxine sodium.

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A daily dose of aspirin 325 mg PO is most beneficial for an adult client with which medical diagnosis?

A client who is a vegetarian has a new prescription for warfarin. The client reports eating leafy green vegetables every day. How should the nurse respond?

The nurse is preparing to administer warfarin sodium 10 mg PO to a client whose international normalized ratio (INR) is 5.0. Which intervention should the nurse implement?

Reference Range:

International 1 normalized ratio (INR) [INR: 0.8 to 1.1]