The nurse is reviewing risk factors in a client who has atherosclerosis.
Which findings are most concerning? (Select all that apply.)

Choice A rationale

Warfarin is a vitamin K antagonist that inhibits the synthesis of vitamin K-dependent clotting factors II, VII, IX, and X. Clients must be instructed to maintain a consistent intake of vitamin K-rich foods, such as leafy green vegetables, to avoid fluctuations in warfarin's anticoagulant effect and to maintain a stable INR.

Choice B rationale

Warfarin therapy itself does not impose driving restrictions. The primary concern is the bleeding risk associated with the medication, which would not typically affect a person's ability to drive. Driving is not a discharge instruction required specifically because of the medication itself.

Choice C rationale

Regular laboratory monitoring of the International Normalized Ratio (INR) is essential to ensure the warfarin dosage is therapeutic and safe. The INR normal range is 0.8-1.2. The therapeutic range for warfarin is typically 2.0-3.0 for most indications. Clients need to understand the importance of these appointments.

Choice D rationale

Warfarin is highly protein-bound and metabolized by the cytochrome P450 enzyme system, making it susceptible to numerous drug-drug interactions. Educating the client about potential interactions with other medications, including over-the-counter drugs, is crucial to prevent either bleeding or clotting episodes.

Choice E rationale

A client's adherence to a medication regimen is significantly enhanced when they understand the purpose of the treatment. Explaining that warfarin prevents dangerous blood clots in conditions like atrial fibrillation or deep vein thrombosis helps the client appreciate the importance of consistent daily dosing.

Choice F rationale

Wearing a Medic Alert bracelet is a critical safety measure for clients on warfarin. In an emergency, this bracelet immediately informs healthcare providers that the person is on an anticoagulant, allowing them to make informed decisions about care and to recognize signs of potential bleeding complications.

Choice A rationale

A blood pressure of 98/58 mm Hg in a client who needs a beta blocker is a significant safety concern. Beta blockers work by blocking the effects of epinephrine, which can cause a decrease in heart rate and blood pressure. Administering a beta blocker to a client with a pre-existing low blood pressure (normotensive range is 120/80 mm Hg) could cause a profound and dangerous drop in blood pressure, leading to hypotension, syncope, and inadequate organ perfusion. This client needs immediate assessment before medication administration.

Choice B rationale

A client needing to use the bathroom after taking captopril is not an immediate priority. While captopril can cause hypotension, the primary concern is the potential for a first-dose hypotensive effect. However, a client's need to void is a common and expected request and does not indicate an acute, life-threatening crisis requiring immediate intervention before other clients.

Choice C rationale

A blood pressure of 188/92 mm Hg, while elevated, is not an immediate life-threatening emergency unless there are signs of end-organ damage (e.g., chest pain, neurological changes). This is considered a hypertensive urgency, which requires a prompt but not immediate intervention to lower the blood pressure gradually. This client is stable and can be assessed after the client in Choice A, who is at risk for a profound hypotensive event.

Choice D rationale

A client needing pain medication before a dressing change is not the highest priority. Pain management is an important aspect of care, but it is not an acute physiological emergency. Delaying pain medication for a short time to address a life-threatening physiological instability in another client is an appropriate triage decision. The client in Choice A is at higher risk for a critical physiological event. .