Examkin

Question

Difficulty: MediumPharmacological Therapies

A practical nurse is caring for an older adult client with a history of atrial fibrillation who is prescribed daily warfarin. During morning rounds, the client appears suddenly confused and restless. The client's most recent International Normalized Ratio (INR) is 5.5. Which of the following actions should the nurse take first?

  1. Withhold the scheduled warfarin and immediately notify the registered nurse of the client's status.Answer
  2. B
    Document the laboratory result in the electronic health record and administer the scheduled dose.
  3. C
    Prepare to independently administer intravenous vitamin K to rapidly reverse the coagulation status.
  4. D
    Attribute the sudden confusion to expected age-related changes and continue routine care.

Answer

The nurse should withhold the scheduled warfarin and immediately notify the registered nurse of the client's status.
An INR of 5.5 is well above the typical therapeutic range of 2.0 to 3.0, indicating a severe risk for bleeding. Furthermore, the client's sudden confusion could be a symptom of an intracranial hemorrhage. The correct action within the practical nurse's scope of practice is to withhold the dose and urgently notify the registered nurse or healthcare provider to ensure patient safety.

Step-by-Step Solution

1
Analyze the client's laboratory data.
The INR of 5.5 is significantly above the therapeutic range of 2.0 to 3.0 for atrial fibrillation.
Identifying abnormal laboratory values is essential to determine if a scheduled medication is safe to administer.
2
Evaluate the client's clinical presentation.
The client is an older adult exhibiting sudden confusion and restlessness.
Acute mental status changes can be a sign of poor perfusion or intracranial bleeding, especially in a client with a high bleeding risk.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The safest and most appropriate action is to withhold the medication and escalate the critical findings to the registered nurse.
The practical nurse cannot safely administer the medication or prescribe antidotes, making prompt reporting the priority.

Key Concept

Pharmacological Therapies and Scope of Practice
Rate this question

Topics

Pharmacological Therapies

More questions from this topic