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. Ensure that the client eats breakfast: Regular insulin is a fast-acting insulin that typically begins to work within 30 minutes to an hour after administration, peaks around 2-3 hours, and can last for up to 6 hours. Therefore, it is crucial that the client eats a meal, such as breakfast, shortly after the insulin is administered to prevent hypoglycemia.
B. Provide a mid-afternoon snack for the client: While snacks may be necessary depending on the client's overall meal and insulin schedule, it is more critical to ensure the client eats the meal immediately following insulin administration to manage blood glucose levels.
C. Assess the client for hypoglycemia around 1500: While monitoring for hypoglycemia is important, it is more critical to ensure the client eats their meal soon after insulin administration to prevent hypoglycemia in the first place.
D. Perform a glucometer reading at 1000: A glucometer reading at 1000 might be useful for monitoring blood glucose levels but ensuring that the client eats a meal promptly is a more immediate and critical action following insulin administration.

A. Obtain a platelet count weekly. B. Take the medication during pregnancy. C. Use folic acid to protect the liver. D. Store the medication at room temperature.

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.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

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]