Examkin

Question

Difficulty: EasyReduction of Risk Potential

A practical nurse working in a rehabilitation facility is reviewing the morning laboratory results for a resident who takes daily oral warfarin for atrial fibrillation. The resident's International Normalized Ratio (INR) is reported as 5.5. Which action is the most appropriate for the nurse to take?

  1. A
    Administer the scheduled warfarin dose and monitor the resident closely for signs of bruising.
  2. B
    Instruct the laboratory to draw another blood sample to confirm the abnormal result.
  3. Withhold any scheduled warfarin doses and notify the supervising registered nurse immediately.Answer
  4. D
    Verify the resident's identity using two patient identifiers before giving the medication.

Answer

Withhold any scheduled warfarin doses and notify the supervising registered nurse immediately.
The therapeutic INR range for a client on warfarin therapy is generally 2.0 to 3.0. An INR of 5.5 is critically elevated and places the client at an immediate high risk for spontaneous bleeding. The nurse must withhold the medication to prevent further elevating the INR and notify the supervising nurse or healthcare provider immediately so that potential dosage adjustments or reversal orders can be managed.

Step-by-Step Solution

1
Analyze the provided laboratory value (INR of 5.5).
Recognize that the value is significantly above the standard therapeutic range for warfarin (typically 2.0 to 3.0).
Identifying abnormal laboratory data is essential for determining medication safety.
2
Identify the primary risk associated with the abnormal finding.
Determine that a supratherapeutic INR places the client at a high risk for spontaneous and severe hemorrhage.
Understanding the clinical implication of the lab value guides prioritization.
3
Select the safest nursing intervention within the practical nurse scope of practice.
Decide to withhold the medication and escalate the critical finding to the RN or healthcare provider.
Preventing harm by stopping the causative agent and communicating with the care team is the priority for risk reduction.

Key Concept

Critical Laboratory Escalation and Risk Mitigation
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic