Level: Clinical
Difficulty: Medium
Subtopic: Cardiovascular assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for cardiovascular assessment during hospitali…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for cardiovascular assessment during hospitalization. The nurse reviews this trend: INR increasing from 2.0 to 4.5 without active bleeding. Which interpretation and action are most appropriate?
Question
A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Ignore the trend because one data point can be explained later.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: A. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.