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Soru

Zorluk: OrtaPharmacological Therapies

A practical nurse (PN) is reviewing the electronic health record of an older adult client who is scheduled to receive a daily dose of oral warfarin. The client's morning international normalized ratio (INR) is 4.84.8. Upon entering the room, the client reports a new, severe headache. Which action should the PN take first?

  1. Withhold the scheduled warfarin and immediately notify the registered nurse (RN) of the laboratory result and the client's headache.Cevap
  2. B
    Administer the scheduled warfarin as prescribed and document the client's headache in the nursing notes.
  3. C
    Administer a prescribed as-needed dose of an oral nonsteroidal anti-inflammatory drug (NSAID) for the headache.
  4. D
    Independently contact the laboratory to draw a repeat blood sample to verify the accuracy of the INR result.

Cevap

Withhold the scheduled warfarin and immediately notify the registered nurse (RN) of the laboratory result and the client's headache.
The client's INR of 4.84.8 is significantly above the standard therapeutic range of 2.02.0 to 3.03.0, indicating a severe risk of bleeding. The sudden onset of a severe headache is a critical warning sign of a potential intracranial hemorrhage. The safest and most appropriate action within the PN's scope of practice is to withhold the dose of warfarin to prevent further anticoagulation and immediately alert the RN so that emergency medical assessment can be initiated.

Adım Adım Çözüm

1
Analyze the client's laboratory data.
The INR of 4.84.8 is supratherapeutic (normal therapeutic range is typically 2.02.0 to 3.03.0), placing the client at high risk for bleeding.
Recognizing critical laboratory values is essential before administering anticoagulants.
2
Evaluate the client's clinical presentation.
The client reports a new, severe headache.
A severe headache in the presence of a high INR is a clinical red flag for a potential intracranial hemorrhage.
3
Determine the appropriate nursing intervention within the PN scope of practice.
The PN must withhold the medication to prevent further bleeding and immediately report both the critical lab and the symptom to the RN.
The PN scope of practice requires reporting critical changes in condition and abnormal lab results to the supervising RN for further medical evaluation.

Anahtar Kavram

The practical nurse must recognize critical laboratory values, identify clinical signs of life-threatening adverse effects, and promptly escalate care to the RN while withholding contraindicated medications.
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Pharmacological Therapies

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