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) Protect the skin from sunlight while taking the drug: Tetracycline is known to increase sensitivity to sunlight, leading to a higher risk of sunburn and skin reactions. Advising clients to protect their skin from sun exposure and to use sunscreen is essential to prevent these adverse effects. This precaution helps mitigate the risk of photosensitivity reactions that are commonly associated with tetracycline use.
B) Take with orange juice to enhance gastrointestinal (GI) absorption: Tetracycline should not be taken with dairy products or antacids, as they can bind with the medication and reduce its absorption. While orange juice can enhance absorption, this is not a standard recommendation for tetracycline. Instead, it is generally advised to take tetracycline with water and avoid substances that could interfere with its absorption.
C) Return to the clinic weekly to obtain serum drug levels: Tetracycline typically does not require regular monitoring of serum drug levels, as it does not have a narrow therapeutic index like some other drugs. Instead, patients are generally advised on how to manage side effects and adherence to the medication regimen, rather than frequent clinic visits for drug level monitoring.
D) Take with milk or antacids to prevent gastrointestinal (GI) irritation: Milk and antacids should be avoided when taking tetracycline because they can bind to the medication and significantly reduce its effectiveness. This instruction could lead to decreased therapeutic efficacy and should be avoided. Tetracycline should be taken on an empty stomach to ensure optimal absorption, avoiding interactions with these substances.

A. Fingerstick glucose. B. Stool color and character. C. Serum hepatic enzymes. D. Serum electrolytes and ammonia.

Correct Answer is D

Explanation

A. Fingerstick glucose: While important in managing diabetes or hypoglycemia, it is not directly related to evaluating the effectiveness of lactulose in treating hepatic encephalopathy.
B. Stool color and character: Lactulose acts as a laxative, and its effectiveness can affect stool characteristics. However, stool color and character are less direct indicators of therapeutic response compared to serum ammonia levels.
C. Serum hepatic enzymes: While liver enzyme levels can provide information about liver function, they do not directly measure the effectiveness of lactulose in managing hepatic encephalopathy. Serum ammonia levels are more specific for this purpose.
D. Serum electrolytes and ammonia: Lactulose is used to treat hepatic encephalopathy by reducing blood ammonia levels. Monitoring serum ammonia levels provides direct feedback on the effectiveness of the medication in treating hepatic encephalopathy. Additionally, serum electrolytes should be monitored because lactulose can lead to electrolyte imbalances due to its laxative effect.

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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

The healthcare provider prescribes the antibiotic tetracycline HCl for an adult client that arrived at an outpatient clinic. Which instruction should the nurse Include in the teaching plan for this client?

Correct Answer is A

Explanation

A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the best information to evaluate the client's therapeutic response to the medication?

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]

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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]