A practical nurse (PN) is reviewing the electronic health record of a client scheduled to receive a routine dose of oral warfarin. The client's morning International Normalized Ratio (INR) is 5.2. Current vital signs reveal a heart rate of 108 beats/min and a blood pressure of 96/58 mm Hg. Which action should the PN take to reduce the client's risk of complications?
- Withhold the scheduled dose of warfarin and immediately alert the registered nurse (RN).Answer
- BDocument the elevated INR value in the client's chart and administer the medication as prescribed.
- CAttribute the mild hypotension and tachycardia to client anxiety and continue routine monitoring.
- DPrepare to independently administer an intravenous (IV) push dose of vitamin K to reverse the bleeding risk.
Answer
The correct action is to withhold the scheduled dose of warfarin and immediately alert the registered nurse (RN).
The client presents with a critically elevated INR (therapeutic range for warfarin is generally 2.0 to 3.0) and borderline vital signs (tachycardia and hypotension) that strongly suggest active internal hemorrhage. The safest and most appropriate action for the practical nurse is to withhold the anticoagulant to prevent further bleeding and immediately alert the registered nurse or healthcare provider to initiate emergency interventions.
Step-by-Step Solution
Key Concept
Prioritization of Critical Laboratory Values and Early Signs of Shock