A nurse is caring for a client prescribed Warfarin. Which nursing action is most appropriate regarding monitoring INR levels and maintaining consistent dietary vitamin K intake?

• 1 Remove the fentanyl patch and clean residual drug from the skin, repeat IV naloxone dosing, and start a continuous IV naloxone infusion typically at two-thirds of the effective bolus dose per hour with continuous monitoring of RR, SpO2, capnography, and sedation for at least 12 to 24 hours given the depot effect of the patch.
• 2 Remove the fentanyl patch for 4 hours until the patient is fully awake and respiratory rate is above 16, then reapply the same patch and provide an order for intravenous naloxone 0.4 mg every 4 hours as needed for sedation or respiratory rate below 10, with plans to discharge the patient after 24 hours of observation if stable.
• 3 Administer a repeat bolus of 0.4 mg intravenous naloxone, assess for response, and if respiratory rate improves to above 12 breaths per minute and sedation score decreases, continue to monitor for 4 hours, then discharge the patient with a home naloxone rescue kit and a plan to follow up with the primary care provider in 1 week.
• 4 Continue to monitor the patient’s respiratory rate and sedation level every 15 minutes for 4 hours without additional intervention, because the initial nasal naloxone dose has a long duration of action and the fentanyl from the patch will be absorbed slowly enough to not cause further respiratory depression. ✓ Correct answer

For study reference only. Always follow current clinical guidelines and your institution’s protocols.