Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


“Record the normal value on the intershift report sheet” is incorrect because the value is high, not normal, and dismisses the subject at hand. “Administer the daily dose of the medication” is incorrect because the next dose should not be administered automatically.


Test-Taking Strategy: Note that the question contains the strategic word “first.” This implies that more than one or all of the options may be partially correct. To choose correctly, you must be familiar with the therapeutic range for this medication. Also, using the steps of the nursing process will direct you to “gather data from the client related to signs of toxicity.” If this question was difficult, review the information about this medication and measurement of its therapeutic serum level.


PTS: 1 DIF: Level of Cognitive Ability: Applying REF: Skidmore-Roth, L. (2010). 2010 Mosby’s nursing drug reference (23rd ed.). St. Louis: Mosby. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Implementation


25. The client is receiving oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse anticipates carrying out a prescription to do which of the following? 1. Hold the next dose of warfarin. 2. Increase the next dose of warfarin. 3. Administer the next dose of warfarin. 4. Stop the warfarin, and administer heparin.


ANS: 1


Rationale: The normal PT is 11.0 to 12.5 seconds for adults. Appropriate therapy for full anticoagulation should prolong the PT by 1.5 to 2 times. Because the value stated is extremely high, the nurse should anticipate that the client would not receive further doses at this time. If the level were too high, then the antidote (vitamin K) could also be prescribed. It would be dangerous to add a different anticoagulant to the client’s regimen at this time (“stop the warfarin, and administer heparin”).


Test-Taking Strategy: To answer this question accurately, you must be familiar with both the normal and the therapeutic PT levels for the client receiving warfarin therapy. Recalling that the normal PT is 11.0 to 12.5 seconds will direct you to “hold the next dose of warfarin.” Review this laboratory test if you had difficulty with this question.


PTS: 1 DIF: Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Planning


Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


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