Level: Clinical
Difficulty: Medium
Subtopic: Anticoagulants
NCLEX: A 45-year-old client in the emergency department is being evaluated for warfarin anticoagulation. Assessment data…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 45-year-old client in the emergency department is being evaluated for warfarin anticoagulation. Assessment data include the client has respiratory rate 10/min and is difficult to arouse after opioid administration. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.