# A nurse is providing discharge teaching to a 65-year-old client newly prescribed warfarin for atrial fibrillation. Which instructions should the nurse include? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=364872&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A nurse is providing discharge teaching to a 65-year-old client newly prescribed warfarin for atrial fibrillation. Which instructions should the nurse include? Select all that apply.

1

Maintain a consistent daily intake of green leafy vegetables rather than avoiding them entirely

2

Have INR checked weekly initially, then per provider schedule

3

Take aspirin or ibuprofen as needed for aches and headaches

4

Use a soft-bristle toothbrush and an electric razor to reduce bleeding risk

5

Take a daily vitamin K supplement to balance the warfarin effect

## Explanation

Warfarin teaching emphasizes consistent vitamin K intake (not avoidance), bleeding precautions, and routine INR monitoring. NSAIDs and aspirin increase bleeding risk and should be avoided unless prescribed. Vitamin K supplementation antagonizes warfarin and is contraindicated.

## In-depth explanation

Clinical Judgment
Warfarin client teaching: consistent vitamin K diet, bleeding precautions, routine INR, avoid NSAIDs, MedicAlert ID. Therapeutic INR for atrial fibrillation: 2.0-3.0. Antidote: vitamin K (slow), 4-factor PCC (urgent). Many drug interactions — check before any new prescription.

Memory Tip
Warfarin = consistent K diet + soft brush/electric razor + INR check + no NSAIDs

KR vs US
AHA atrial fibrillation guidelines and Korean Society of Cardiology guidelines align: warfarin INR 2.0-3.0 for AFib. DOACs (apixaban, rivaroxaban) increasingly preferred over warfarin in non-valvular AFib. Korean tertiary cardiology clinics use the same INR target.

## Clinical scenario

Clinical Practice Guide
Warfarin client education bundle:
- Consistent dietary vitamin K: about 90 mcg/day for women, 120 mcg/day for men. Eat the same amount of leafy greens daily; do not stop or start abruptly.
- Bleeding precautions: soft toothbrush, electric razor, fall prevention, no contact sports, watch for bruising, melena, hematuria, gum bleeding
- INR monitoring: weekly until stable, then every 4-6 weeks. Target 2.0-3.0 for AFib and DVT/PE; 2.5-3.5 for mechanical mitral valve
- Drug interactions: NSAIDs, antibiotics, herbals (St. John wort, ginkgo), grapefruit juice — check before any new med
- MedicAlert ID at all times
- Hold for procedures per provider, often 5 days pre-op

Caution
Reversal: vitamin K 1-10 mg PO/IV for elevated INR; 4-factor PCC (Kcentra) plus vitamin K for major bleeding. Fresh frozen plasma is a slower secondary option. Do not use FFP alone if PCC is available.

## Key concepts

- **Warfarin** — Vitamin K antagonist that inhibits hepatic synthesis of clotting factors II, VII, IX, X. Used for AFib, mechanical valves, DVT/PE prevention and treatment. Monitored by INR. Therapeutic range 2.0-3.0 for most indications. Antidote: vitamin K and 4-factor PCC.
- **INR (International Normalized Ratio)** — Standardized PT measure used for warfarin monitoring. Therapeutic 2.0-3.0 for AFib, DVT, PE; 2.5-3.5 for mechanical mitral valve. Below 2 = thrombosis risk; above target = bleeding risk. Frequency: weekly initially, every 4-6 weeks once stable.
- **Bleeding precautions** — Standard teaching for clients on anticoagulants: soft-bristle toothbrush, electric razor, fall prevention, MedicAlert ID, no contact sports, monitor for bruising, melena, hematuria, gum bleeding, and severe headache.

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