When administering ceftriaxone sodium IV to a client before surgery, which assessment finding requires immediate intervention by the nurse?

A) Hypertension: Phenytoin is primarily used to manage seizures, and hypertension is not a common side effect associated with its use. While monitoring blood pressure is important for overall health, it is not specifically indicated for detecting common side effects of phenytoin.
B) Peripheral edema: Peripheral edema is not a typical side effect of phenytoin. Common side effects are usually related to oral health and skin changes rather than fluid retention or swelling in the extremities.
C) Hematuria: Hematuria, or blood in the urine, is not commonly associated with phenytoin use. This side effect is more relevant to other medications or conditions, and while monitoring for overall health changes is important, it is not a primary concern with phenytoin.
D) Gingival hyperplasia: Phenytoin is well-known for causing gingival hyperplasia, which is the overgrowth of gum tissue. This is a common and notable side effect of long-term phenytoin use, making it important for the nurse to assess for this symptom in clients receiving the medication.

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.