The practical nurse (PN) learns in the change-of-shift report that the prothrombin time (PT) and International Normalized Ratio (INR) values are prolonged for a client who is receiving warfarin. The PN should review which additional laboratory test result for the client?
Protein.
Potassium.
Hemoglobin.
White blood cell count.
The Correct Answer is C
A. Protein: Although low protein levels can influence drug binding and metabolism, they are not directly related to the anticoagulant effects or bleeding risks associated with prolonged PT/INR values. Protein monitoring is not the priority in this context.
B. Potassium: Potassium levels reflect electrolyte balance and cardiac function but are not affected by warfarin therapy. Abnormal potassium results would not explain or correlate with prolonged clotting times.
C. Hemoglobin: Prolonged PT and INR increase the risk of bleeding, which can lead to anemia. Reviewing hemoglobin levels helps determine whether the client has experienced occult or active blood loss as a result of excessive anticoagulation.
D. White blood cell count: WBC count reflects immune system activity and infection status, not coagulation function. It provides no direct information about bleeding risk or the effects of warfarin therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Catheterize the client for residual urine volume: Catheterization is an invasive procedure and should not be the first action. It is only indicated if there are signs of urinary retention or incomplete bladder emptying after assessment.
B. Measure the next voiding, then palpate the client’s bladder: Frequent urination after delivery is often normal due to postpartum diuresis as the body eliminates excess fluid retained during pregnancy. Measuring the next void and checking for bladder distention helps determine whether the urination is adequate or related to incomplete emptying.
C. Obtain a specimen for urine culture and sensitivity: A culture is appropriate only if there are signs of infection such as dysuria, urgency, or fever. In this case, the client’s concern reflects frequency without other symptoms, so infection is less likely.
D. Evaluate for normal involution, then massage the fundus: Fundal massage is indicated for uterine atony or excessive bleeding, not urinary frequency. The client’s symptom relates more to bladder function than uterine contraction.
Correct Answer is D
Explanation
A. Reinforce PCA pump teaching: Teaching about PCA use is important, but it is not the immediate priority when a client shows signs of lethargy. Education can be addressed later, once the client’s condition has been stabilized and safety is ensured.
B. Check the IV insertion site for swelling: Inspecting the IV site for infiltration or phlebitis is a routine step, but it does not address the potential systemic effect of morphine causing central nervous system depression.
C. Determine the client's pain scale rating: Assessing pain level is typically part of routine evaluation for clients on PCA, but when lethargy develops, the focus must shift to assessing possible opioid toxicity rather than pain relief effectiveness.
D. Measure the client's vital signs: Obtaining vital signs is the most immediate and appropriate action. Respiratory depression, hypotension, or bradycardia may indicate opioid overdose or excessive sedation. Prompt assessment allows the PN to recognize early signs of morphine toxicity and intervene quickly to prevent respiratory compromise.
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