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Difficulty: MediumPharmacological Therapies

While preparing morning treatments on a telemetry unit, a licensed practical nurse checks the latest laboratory values for a client who takes warfarin sodium daily for atrial fibrillation. The laboratory report indicates an International Normalized Ratio (INR) of 5.5. What is the appropriate nursing action concerning the morning dose of this anticoagulant?

  1. A
    Deliver the ordered dose and observe the client for hematuria or ecchymosis.
  2. B
    Reduce the amount of medication administered to safely lower the coagulation level.
  3. Hold the scheduled dose and urgently report the elevated value to the primary registered nurse.Answer
  4. D
    Administer the standard dose but advise the client to use a soft-bristled toothbrush.

Answer

Hold the scheduled dose and urgently report the elevated value to the primary registered nurse.
The therapeutic INR range for a client on warfarin therapy is typically 2.0 to 3.0. An INR of 5.5 is critically high and indicates a significant risk for spontaneous bleeding. The LPN's scope of practice requires recognizing this critical laboratory value, withholding the medication that would exacerbate the condition, and immediately reporting the finding to the supervising registered nurse or healthcare provider for further medical orders.

Step-by-Step Solution

1
Identify the client's current medication and the corresponding laboratory result.
The client is taking warfarin, an anticoagulant, and has an INR of 5.5.
Evaluating relevant laboratory values prior to medication administration is essential for client safety.
2
Compare the client's INR to the expected therapeutic range for warfarin.
The normal therapeutic INR range for a client with atrial fibrillation is 2.0 to 3.0. An INR of 5.5 is critically high.
Recognizing a supratherapeutic level determines whether the medication is safe to administer.
3
Determine the appropriate nursing intervention based on the critical laboratory finding and the LPN scope of practice.
The nurse must hold the medication to prevent hemorrhage and immediately escalate the finding to the supervising registered nurse.
Administering the drug would increase the bleeding risk, and altering dosages independently is outside the LPN scope of practice.

Key Concept

Recognizing critical laboratory values related to pharmacological therapies and adhering to pre-administration withholding criteria within the LPN scope of practice.
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Topics

Pharmacological Therapies

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