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Difficulty: Very hardPharmacological Therapies

An older adult client is receiving daily oral warfarin for atrial fibrillation management. The electronic health record displays a morning International Normalized Ratio (INR) of 5.2. When the practical nurse enters the room, the client complains of a new, severe headache and asks for their prescribed as-needed acetaminophen. Which action is the priority for the practical nurse?

  1. Withhold all medications and immediately alert the registered nurse about the client's symptoms and laboratory values.Answer
  2. B
    Provide the prescribed acetaminophen for pain relief and monitor the client closely for visible signs of bleeding.
  3. C
    Conduct a comprehensive neurological assessment to determine the cause of the headache before proceeding.
  4. D
    Withhold the scheduled warfarin dose and document the abnormal laboratory result in the client's chart.

Answer

Withhold all medications and immediately alert the registered nurse about the client's symptoms and laboratory values.
An INR of 5.2 is dangerously elevated above the standard therapeutic range of 2.0 to 3.0 for atrial fibrillation. A new, severe headache in a client with supratherapeutic anticoagulation strongly indicates a possible intracranial hemorrhage. The priority is physiological safety; therefore, the practical nurse must withhold all medications and immediately escalate these critical findings to the registered nurse for comprehensive evaluation.

Step-by-Step Solution

1
Evaluate the laboratory results against normal therapeutic ranges.
An INR of 5.2 is identified as critically supratherapeutic (normal therapeutic range for atrial fibrillation is 2.0 to 3.0).
High INR values indicate an extreme risk for spontaneous hemorrhage.
2
Correlate the client's new symptom with the critical laboratory value.
The new, severe headache is recognized as a hallmark sign of a potential life-threatening intracranial hemorrhage.
Identifying complications of pharmacological therapies is essential for client safety.
3
Determine the appropriate intervention based on practical nursing scope of practice.
The decision is made to withhold all medications (which could mask symptoms or worsen bleeding) and escalate the emergent finding.
Acute, life-threatening changes require immediate registered nurse or provider assessment.

Key Concept

Recognizing critical medication adverse effects, prioritizing physiological safety, and adhering to the practical nurse scope of practice during a potential emergency.
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Topics

Pharmacological Therapies

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