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Difficulty: EasyReduction of Risk Potential

While reviewing morning laboratory reports, a practical nurse notes that a client taking daily warfarin has an International Normalized Ratio (INR) of 5.8. Which action is the priority for the nurse to take?

  1. A
    Document the INR value in the electronic health record and continue routine care.
  2. B
    Administer the scheduled morning dose of warfarin as prescribed.
  3. Withhold any scheduled warfarin and immediately notify the registered nurse.Answer
  4. D
    Independently order a repeat blood test to confirm the elevated laboratory value.

Answer

The correct action is to withhold any scheduled warfarin and immediately notify the registered nurse.
An INR of 5.8 is dangerously above the therapeutic range, indicating a severe risk for bleeding. The safest and most appropriate action within the practical nurse scope of practice is to withhold any further doses of the anticoagulant and promptly communicate the critical laboratory value to the registered nurse or healthcare provider so that medical interventions (such as administering vitamin K) can be initiated.

Step-by-Step Solution

1
Identify the normal therapeutic range for INR.
The typical therapeutic range for a client on warfarin is generally 2.0 to 3.0.
Understanding baseline therapeutic levels is necessary to interpret laboratory results accurately.
2
Analyze the client's current INR value.
The client's INR is 5.8, which is critically high.
A critically high INR indicates that the blood is clotting too slowly, severely increasing the client's risk of spontaneous bleeding.
3
Determine the appropriate nursing intervention within the practical nurse scope.
The nurse must withhold the medication and notify the supervising RN or provider.
Preventing harm (withholding the dose) and escalating critical findings are fundamental safety responsibilities of the practical nurse.

Key Concept

Critical Laboratory Evaluation and Escalation
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Topics

Reduction of Risk Potential

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