Level: Clinical
Difficulty: Medium
Subtopic: Anticoagulants
NCLEX: A 34-year-old client on a telemetry unit is being evaluated for warfarin anticoagulation. Assessment data include…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 34-year-old client on a telemetry unit is being evaluated for warfarin anticoagulation. Assessment data include INR 4.6 without active bleeding but with dark tarry stools. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Reassessing the client after an appropriate intervention.
C. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
B. Reassessing the client after an appropriate intervention.
C. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: C. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.