# A 78-year-old client comes to the clinic for a routine medication review. After reading the EHR tabs (History, Vital Signs, Labs, Orders, Notes), which finding is most concerning and warrants the priority intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372268&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question A 78-year-old client comes to the clinic for a routine medication review. After reading the EHR tabs (History, Vital Signs, Labs, Orders, Notes), which finding is most concerning and warrants the priority intervention? History Vitals Labs Orders Notes 78-year-old female. Hypertension, atrial fibrillation, depression, knee osteoarthritis, mild chronic kidney disease (baseline eGFR 45). Lives independently. Recent knee pain after gardening 2 weeks ago. BP 134/78, HR 72, RR 14, T 36.7 C, SpO2 97 percent on room air. No acute distress. INR 4.6 (target 2.0 to 3.0); Hgb 11.2; K 5.4 mEq/L (ref 3.5-5.0); Na 138; Creatinine 1.4 mg/dL (baseline 1.0 to 1.1); eGFR 45 mL/min/1.73 m2; AST and ALT normal. Warfarin 5 mg PO daily; lisinopril 20 mg PO daily; spironolactone 25 mg PO daily; metoprolol succinate 25 mg PO daily; sertraline 50 mg PO daily. Client reports she has been taking ibuprofen 400 mg every 6 hours over the counter for the past 2 weeks for knee pain. She did not tell her prescriber. She denies black stools or new bleeding. 1 Blood pressure 134/78 mmHg in a client treated for chronic hypertension ✕ 2 Self-added ibuprofen in a client on warfarin, lisinopril, and spironolactone with mild CKD, K 5.4 mEq/L, and rising creatinine ✕ 3 Sertraline 50 mg PO daily, taken consistently for the past 3 years ✕ 4 Metoprolol succinate 25 mg PO daily for permanent atrial fibrillation ✕ ## Explanation Why option 2 The self-added ibuprofen creates three converging dangers: (1) ibuprofen + warfarin sharply raises GI bleed risk and pushes INR upward; (2) ibuprofen + lisinopril + spironolactone reduces renal perfusion and worsens AKI in mild CKD; (3) spironolactone + lisinopril plus ibuprofen-induced AKI further raises serum potassium toward dangerous territory. K 5.4 mEq/L and rising creatinine are early warnings that the cascade has begun. The priority is to discontinue ibuprofen, recheck INR, BMP, and review safer analgesic options. Why not the others BP 134/78 is acceptable for an older client with treated HTN. Sertraline at a stable dose is not the acute concern. Metoprolol succinate at 25 mg is a routine AF rate-control dose without a red-flag interaction in this regimen. ## In-depth explanation Step 1 — Read across the tabs History: 78F with HTN, AF, depression, osteoarthritis, mild CKD (eGFR 45). Vitals: BP 134/78, HR 72, no acute distress. Labs: K 5.4 (high), Cr 1.4 (rising), eGFR 45. Orders: warfarin, lisinopril, spironolactone, metoprolol, sertraline. Notes: client added OTC ibuprofen 400 mg every 6 hours for knee pain over the past 2 weeks. Step 2 — Map interactions Ibuprofen + warfarin: NSAID inhibits platelet function and can elevate INR — major bleed risk. Ibuprofen + lisinopril + spironolactone: NSAID lowers renal prostaglandins, dropping GFR; lisinopril and spironolactone both raise potassium. The client has CKD baseline. Step 3 — Recognize the early signal K 5.4 and rising Cr are the early-stage signals of NSAID-mediated AKI in a polypharmacy regimen. Waiting for K 6.5 or syncope from bleeding is too late. Step 4 — Act Discontinue ibuprofen now, switch to acetaminophen with shared decision making, recheck INR and BMP, hold spironolactone or lisinopril if K rises further, educate the client on OTC drug review with the prescriber. Key concept NCLEX rewards reading across the EHR (orders + notes + labs + history). A single normal-looking BP can hide a polypharmacy danger when an OTC drug is hidden in the Notes tab. ## Clinical scenario Scenario 78-year-old female, routine medication review at the primary care clinic. Mild CKD (eGFR 45), AF on warfarin, treated HTN, depression, knee osteoarthritis. Today Five EHR tabs (History, Vital Signs, Labs, Orders, Notes) reveal a self-added OTC ibuprofen, rising creatinine, and K 5.4. The nurse must identify the priority concern. Background Older adults are vulnerable to drug-drug interactions and NSAID-related AKI. The Beers Criteria flag chronic NSAIDs for clients with CKD or on RAAS-blocking therapy. ## Key concepts - **Beers Criteria** — AGS-published list of potentially inappropriate medications for older adults. Chronic NSAIDs are flagged for clients with CKD, heart failure, or on RAAS-blocking therapy. - **NSAID and renal function** — NSAIDs inhibit COX-mediated renal prostaglandins, reducing GFR and predisposing to acute kidney injury, hyperkalemia, and worsening hypertension, especially in CKD or with concurrent ACEI, ARB, or diuretic. - **Polypharmacy** — Concurrent use of five or more medications. Increases risk of adverse drug events, drug-drug interactions, falls, and cognitive impairment in older adults. 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