Level: Clinical
Difficulty: Medium
Subtopic: Anticoagulants
NCLEX: A 55-year-old client in postanesthesia care is being evaluated for warfarin anticoagulation. Assessment data incl…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 55-year-old client in postanesthesia care is being evaluated for warfarin anticoagulation. Assessment data include the client reports nausea and vomiting after taking a new oral medication. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that reports nausea and vomiting after taking a new oral medication.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that reports nausea and vomiting after taking a new oral medication.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that reports nausea and vomiting after taking a new oral medication.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.