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Zorluk: KolayPharmacological Therapies

A client who takes warfarin for atrial fibrillation is scheduled to receive their daily dose. The practical nurse reviews the client's morning laboratory report and notes an International Normalized Ratio (INR) of 5.8. Which action should the nurse take?

  1. Withhold the scheduled dose and immediately report the laboratory findings to the registered nurse.Cevap
  2. B
    Administer the medication as prescribed as long as the client shows no visible signs of bleeding.
  3. C
    Instruct the unlicensed assistive personnel to monitor the client's stool and urine for blood.
  4. D
    Verify the client's identity using their room number and administer the scheduled dose.

Cevap

The practical nurse should withhold the scheduled dose of warfarin and immediately report the critically high INR finding to the registered nurse.
For a client taking warfarin for atrial fibrillation, the standard therapeutic International Normalized Ratio (INR) is between 2.0 and 3.0. An INR of 5.8 is critically high and indicates excessive anticoagulation. The practical nurse must prioritize client safety by withholding the medication to prevent hemorrhage and immediately reporting the finding to the registered nurse or healthcare provider.

Adım Adım Çözüm

1
Evaluate the client's morning laboratory results prior to medication administration.
The client has an INR of 5.8.
Warfarin dosage is directly guided by the INR level, which must be checked to ensure administration is safe.
2
Compare the client's INR to the expected therapeutic range.
The result of 5.8 is critically high, as the standard therapeutic range is typically 2.0 to 3.0 for a client with atrial fibrillation.
Recognizing critical lab values is essential to prevent severe medication toxicity.
3
Determine the appropriate nursing intervention based on the practical nurse scope of practice.
The medication must be withheld and the registered nurse or provider must be notified.
Administering the medication would cause harm, and abnormal findings must be escalated to the supervising nurse.

Anahtar Kavram

Recognizing critical laboratory values and withholding medication to prevent client harm.
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Pharmacological Therapies

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