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Difficulty: MediumPharmacological Therapies

A practical nurse is caring for a client with atrial fibrillation who is prescribed a daily dose of oral warfarin. The client is also scheduled to receive a seasonal influenza vaccine. Upon reviewing the morning laboratory results, the nurse notes an international normalized ratio (INR) of 6.56.5. Which of the following actions is the priority for the practical nurse?

  1. A
    Administer the oral warfarin as scheduled and document the INR result in the electronic health record.
  2. B
    Administer an intravenous (IV) push dose of vitamin K to reverse the anticoagulant effects.
  3. Withhold the scheduled oral warfarin and immediately report the INR result to the registered nurse.Answer
  4. D
    Administer the seasonal influenza vaccine intramuscularly as scheduled.

Answer

The priority action is to withhold the scheduled oral warfarin and immediately report the critical INR result to the registered nurse.
The client's international normalized ratio (INR) of 6.56.5 is significantly elevated above the standard therapeutic range of 2.0 to 3.0 for a client with atrial fibrillation, indicating a critical risk for hemorrhage. The priority action for the practical nurse is to ensure client safety by withholding the scheduled warfarin and immediately escalating this critical laboratory value to the registered nurse or provider for further medical orders.

Step-by-Step Solution

1
Evaluate the client's morning laboratory results against the scheduled medications.
The INR of 6.5 is identified as critically high compared to the normal therapeutic range.
Safe medication administration requires verifying that relevant laboratory values are within safe limits prior to administration.
2
Determine the appropriate clinical intervention based on the abnormal finding.
The scheduled dose of warfarin must be withheld.
Administering additional warfarin would further increase the INR and place the client at an extreme risk for spontaneous hemorrhage.
3
Identify the correct action within the practical nurse scope of practice.
The nurse must report the critical value to the supervising registered nurse or provider.
Practical nurses are responsible for monitoring client data, recognizing critical abnormalities, and escalating them appropriately to ensure client safety.

Key Concept

Monitoring for adverse effects and escalating critical laboratory values associated with pharmacological therapies.
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Topics

Pharmacological Therapies

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