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NCLEX · Pharmacological Therapies

A client taking warfarin has an INR of 4.8 (therapeutic range 2.0–3.0). The nurse assesses for which priority finding?

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Correct answer

Bleeding — assess for haematuria (pink/red urine), haematochezia (blood in stool), unusual bruising, prolonged bleeding from cuts, gum bleeding, and any headache or neurological change (intracranial bleed)

  1. A Bleeding — assess for haematuria (pink/red urine), haematochezia (blood in stool), unusual bruising, prolonged bleeding from cuts, gum bleeding, and any headache or neurological change (intracranial bleed)
  2. B Tachycardia
  3. C Hyperglycaemia
  4. D Muscle cramps

Why this is the answer

SUPRATHERAPEUTIC INR (4.8 vs target 2-3): This represents excessive anticoagulation — significantly increased bleeding risk.

Assessment priorities: Urine colour (haematuria); stool colour/occult blood (GI bleed); skin for excessive bruising or haematomas; neurological status (headache, confusion, focal deficits = possible intracranial haemorrhage); injection/IV sites for prolonged bleeding.

Critical: Any neurological change + supratherapeutic INR = possible intracranial bleed = IMMEDIATE emergency response.

Nursing actions: Do not administer the next warfarin dose; notify RN/provider with INR value; anticipate: hold warfarin; possibly vitamin K administration; possible fresh frozen plasma if active major bleeding.

Follow-up: Repeat INR; dietary review (increased vitamin K intake?); medication interactions (new antibiotics, NSAIDs).

Pn scope: Assess for bleeding, hold warfarin, notify — do not independently administer vitamin K without order.

Source: NCLEX-PN Physiological — Anticoagulation, Supratherapeutic INR Management

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About this topic: Pharmacological Therapies

Pharmacological therapies questions cover medication administration, dosage calculation, the rights of medication administration, common drug classes and their side effects, and when to hold a medication and report. This is one of 18 PN: Physiological Integrity questions on pharmacological therapies, each with a full explanation on a single study page.

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