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Difficulty: EasyReduction of Risk Potential

A practical nurse is monitoring a client who recently started taking warfarin, an oral anticoagulant. Which findings indicate an increased risk for severe complications and require immediate escalation to the registered nurse? (Select all that apply)

  1. The client vomits material that resembles coffee grounds.Answer
  2. An International Normalized Ratio (INR) laboratory result of 6.2.Answer
  3. The client reports the sudden onset of a severe headache.Answer
  4. D
    A reported platelet count of 220,000/mm³.
  5. E
    A measured resting heart rate of 74 beats per minute.

Answer

The findings that require immediate escalation are vomiting material resembling coffee grounds, an INR result of 6.2, and the sudden onset of a severe headache.
The correct answers identify critical indicators of active internal bleeding (coffee-ground emesis, sudden severe headache) and a critically high laboratory value (INR of 6.2) that predisposes the client to spontaneous hemorrhage. These findings demonstrate an immediate threat to client safety and require urgent escalation to the registered nurse for intervention.

Step-by-Step Solution

1
Analyze the client's current medication therapy and associated risks.
The client is taking warfarin, an anticoagulant that significantly increases the risk of bleeding.
Understanding the medication profile helps anticipate specific complications, such as hemorrhage.
2
Evaluate the clinical findings for signs of active bleeding or target organ damage.
Coffee-ground emesis indicates gastrointestinal bleeding, and a severe headache may indicate intracranial bleeding.
Internal bleeding is a medical emergency that threatens physiological integrity and requires prompt intervention.
3
Assess the provided laboratory values and vital signs against normal parameters.
An INR of 6.2 is critically high. The platelet count of 220,000/mm³ and the heart rate of 74 bpm are within normal limits.
Only abnormal, high-risk findings should be escalated to the registered nurse.

Key Concept

Reduction of Risk Potential: Anticoagulant Therapy and Bleeding Precautions
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Topics

Reduction of Risk Potential

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