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 A

Explanation

A) Coronary artery disease: It is crucial to assess for a history of coronary artery disease (CAD) before administering sumatriptan, as the medication is a serotonin receptor agonist that can cause vasoconstriction of coronary arteries. This can increase the risk of serious cardiovascular events, such as heart attack or stroke, particularly in clients with preexisting CAD.

B) Seasonal allergic rhinitis: While seasonal allergic rhinitis may be a concern for other medications due to potential allergic reactions or interactions, it is not directly related to the administration of sumatriptan. This condition does not pose a significant risk with the use of sumatriptan.

C) Type 2 diabetes mellitus: Although type 2 diabetes mellitus is an important consideration in the overall health management of a client, it is not the most critical condition to assess before administering sumatriptan. However, if the client has diabetes with associated complications like cardiovascular disease, this would increase concern for using sumatriptan.

D) Irritable bowel syndrome: Irritable bowel syndrome (IBS) is a gastrointestinal disorder that typically does not influence the decision to administer sumatriptan. While IBS may affect a client’s comfort or medication regimen, it does not present the same immediate risks as coronary artery disease when using sumatriptan.

A. Restlessness. B. Decreased appetite. C. Intolerance to cold. D. Constipation.

Correct Answer is A

Explanation

A. Restlessness: Restlessness is a sign of excessive levothyroxine sodium, which can lead to symptoms of hyperthyroidism. Other signs include palpitations, nervousness, and insomnia. Overmedication can accelerate metabolism and cause these symptoms.
B. Decreased appetite: Decreased appetite is not typically associated with overmedication of levothyroxine. Instead, a decreased appetite might be related to other conditions or medications but is not a primary indicator of excessive thyroid hormone.
C. Intolerance to cold: Intolerance to cold is more indicative of hypothyroidism or insufficient dosing of levothyroxine rather than overmedication. Excessive levothyroxine usually causes symptoms of hyperthyroidism, such as heat intolerance.
D. Constipation: Constipation is more commonly associated with hypothyroidism or insufficient levothyroxine dosing. Overmedication generally leads to symptoms like diarrhea rather than constipation.

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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

Before administering the initial dose of sumatriptan succinate to a client with a migraine headache, it is most important to determine if the client's history includes which problem?

Correct Answer is A

Explanation

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.

Correct Answer is A

Explanation

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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]