Video Library
Nursing interventions and care
Nursing interventions and care ( 7 Questions)
A nurse is caring for a client who has been prescribed warfarin for atrial fibrillation. The nurse notices that the client's INR is 6.5. What should the nurse do first?
Vitamin K is an antidote for warfarin overdose, but it should not be given without a provider's order. It may also take several hours to reverse the anticoagulation effect.
Notifying the provider is an important step, but it is not the first action. The nurse should assess the client's condition before calling the provider.
Holding the next dose of warfarin may prevent further anticoagulation, but it does not address the current risk of bleeding. The nurse should assess and intervene for bleeding before holding the medication.
A high INR indicates that the client is at risk of bleeding due to excessive anticoagulation. The nurse should first assess for signs of bleeding, such as bruising, petechiae, hematuria, or melena. Then, the nurse should notify the provider and follow orders to reverse the anticoagulation effect, such as administering vitamin K or fresh frozen plasma. Holding the next dose of warfarin may be appropriate, but it is not the priority action.
A high INR indicates that the client is at risk of bleeding due to excessive anticoagulation. The nurse should first assess for signs of bleeding, such as bruising, petechiae, hematuria, or melena.
Then, the nurse should notify the provider and follow orders to reverse the anticoagulation effect, such as administering vitamin K or fresh frozen plasma.
Holding the next dose of warfarin may be appropriate, but it is not the priority action.
Incorrect choices:
a) Administer vitamin K: Vitamin K is an antidote for warfarin overdose, but it should not be given without a provider's order. It may also take several hours to reverse the anticoagulation effect.
b) Notify the provider: Notifying the provider is an important step, but it is not the first action. The nurse should assess the client's condition before calling the provider.
c) Hold the next dose of warfarin: Holding the next dose of warfarin may prevent further anticoagulation, but it does not address the current risk of bleeding. The nurse should assess and intervene for bleeding before holding the medication.