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Zorluk: ZorPharmacological Therapies

A client being treated for a deep vein thrombosis is receiving daily oral warfarin. During morning data collection, the client reports passing dark, tarry stools. The client's skin is pale, and the practical nurse notes a blood pressure of 88/52 mm Hg88/52\text{ mm Hg} and an apical pulse of 114 beats/min114\text{ beats/min}. The morning international normalized ratio (INR) result is 4.84.8. Which action should the practical nurse take first?

  1. Withhold the scheduled warfarin dose and immediately alert the registered nurse.Cevap
  2. B
    Notify the primary health care provider to request a stat order for intravenous phytonadione.
  3. C
    Assist the client to a resting position in bed and recheck the vital signs in one hour.
  4. D
    Administer the scheduled warfarin because an INR of 4.8 is within the therapeutic target for deep vein thrombosis.

Cevap

The correct action is to withhold the scheduled warfarin dose and immediately alert the registered nurse.
The client is exhibiting undeniable signs of active gastrointestinal hemorrhage (melena) and hypovolemic shock (hypotension and tachycardia), compounded by a dangerously elevated INR of 4.8. The most critical nursing action is to prevent further harm by withholding the anticoagulant and immediately escalating the situation to the registered nurse, who will perform an advanced assessment and collaborate with the health care provider for emergency stabilization.

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1
Analyze the client's subjective and objective physical findings.
The client has dark, tarry stools (melena), pale skin, hypotension (88/52 mm Hg88/52\text{ mm Hg}), and tachycardia (114 beats/min114\text{ beats/min}).
These combined findings are classic indicators of active gastrointestinal bleeding and impending hypovolemic shock.
2
Interpret the laboratory data in the context of the prescribed medication.
The INR is 4.84.8.
The therapeutic INR range for a deep vein thrombosis is 2.02.0 to 3.03.0. A result of 4.84.8 is critically elevated, placing the client at severe risk for hemorrhage.
3
Determine the safest action within the practical nurse's scope of practice.
The medication must be withheld, and the registered nurse must be notified immediately.
The practical nurse cannot administer a medication that is actively causing harm. Because the client is unstable, the registered nurse must immediately take over assessment and coordinate emergency interventions with the provider.

Anahtar Kavram

Monitoring for adverse pharmacological effects and recognizing the need for immediate escalation in unstable clients.
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Pharmacological Therapies

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