Level: Clinical
Difficulty: Medium
Subtopic: Anticoagulants
NCLEX: A client on warfarin has INR 4.8 and no active bleeding. What is the nurse’s best action?
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A client on warfarin has INR 4.8 and no active bleeding. What is the nurse's best action?
Question
A. Hold the scheduled warfarin dose and notify the provider per protocol.
B. Give the warfarin because the client has no visible bleeding.
C. Encourage extra green leafy vegetables to balance the INR.
D. Delegate INR interpretation to UAP and continue the dose.
B. Give the warfarin because the client has no visible bleeding.
C. Encourage extra green leafy vegetables to balance the INR.
D. Delegate INR interpretation to UAP and continue the dose.
Rationale
Correct answer: A. Hold the scheduled warfarin dose and notify the provider per protocol.
Rationale: Supratherapeutic INR increases bleeding risk; hold the dose and notify the provider per protocol.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Supratherapeutic INR increases bleeding risk; hold the dose and notify the provider per protocol.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.