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Difficulty: MediumReduction of Risk Potential

During morning rounds, a practical nurse evaluates a 7171-year-old client who takes oral warfarin for atrial fibrillation. The client's most recent laboratory report reveals an International Normalized Ratio (INR) of 5.85.8. The current vital signs show a heart rate of 112112 beats per minute and a blood pressure of 92/56 mm Hg92/56\text{ mm Hg}. The client reports feeling unusually fatigued and dizzy when sitting up. What is the priority action for the nurse?

  1. Instruct the client to remain in bed and immediately report the findings to the registered nurse.Answer
  2. B
    Document the mild hypotension and tachycardia as expected morning variations and recheck in one hour.
  3. C
    Hold any further doses of the anticoagulant and wait until the provider rounds to discuss the laboratory results.
  4. D
    Prepare and administer an intravenous dose of vitamin K to quickly correct the coagulation abnormality.

Answer

The priority action is to instruct the client to remain in bed for safety and immediately report the critical laboratory value and borderline vital signs to the registered nurse.
An INR of 5.85.8 is critically elevated. When combined with tachycardia, hypotension, and dizziness, this strongly suggests acute internal bleeding. The practical nurse's priority is to minimize injury risk by keeping the client in bed and to immediately escalate these critical findings to the registered nurse for urgent medical intervention.

Step-by-Step Solution

1
Analyze the laboratory value.
An INR of 5.85.8 is recognized as critically high, placing the client at severe risk for hemorrhage.
The normal therapeutic INR range for atrial fibrillation is typically 2.02.0 to 3.03.0.
2
Evaluate the current vital signs and client symptoms.
Tachycardia (112112 bpm), hypotension (92/56 mm Hg92/56\text{ mm Hg}), and dizziness are identified.
These findings represent early clinical indicators of potential internal bleeding and impending hypovolemic shock.
3
Determine the priority nursing action within the practical nurse scope of practice.
The nurse must ensure immediate client safety by maintaining bed rest and escalating the findings.
The client requires urgent medical intervention and advanced assessment by a registered nurse or provider that cannot be delayed.

Key Concept

Recognizing Early Signs of Hemorrhage and Escalating Critical Findings
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Topics

Reduction of Risk Potential

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