Level: Clinical
Difficulty: Medium
Subtopic: Mobility and positioning
NCLEX: A 55-year-old client after abdominal surgery is being evaluated for nursing care related to mobility and position…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 55-year-old client after abdominal surgery is being evaluated for nursing care related to mobility and positioning. 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. Ignore the trend because one data point can be explained later.
B. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
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. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
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: B. 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.