# A 76-year-old client on long-term warfarin (target INR 2.0–3.0) calls the clinic with bleeding gums and a few small bruises. Today INR is 5.5 and the client is hemodynamically stable. The provider orders the following. Which order does the nurse expect to be most appropriate?

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> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 76-year-old client on long-term warfarin (target INR 2.0–3.0) calls the clinic with bleeding gums and a few small bruises. Today INR is 5.5 and the client is hemodynamically stable. The provider orders the following. Which order does the nurse expect to be most appropriate?

## Option

1. Hold the next 1–2 doses of warfarin, give oral vitamin K (phytonadione) 1–2.5 mg as ordered, recheck INR in 24 hours, and reinforce bleeding precautions. **✔ Correct answer**
2. Continue the current warfarin dose as ordered, recheck INR at the next routine visit in 4 weeks, and reassure the client that mild bruising is expected with anticoagulants.
3. Administer 4-factor prothrombin complex concentrate (PCC) intravenously and give intravenous vitamin K 10 mg slowly, then reassess INR within 12 hours.
4. Discontinue warfarin permanently, start aspirin 81 mg once daily, and schedule a follow-up appointment in 3 months for re-evaluation without further anticoagulation monitoring.

**Correct answer: 1**

## Explanation

Warfarin INR-based reversal — graded approach (CHEST guideline)
Management of supratherapeutic INR depends on the INR value AND the presence/severity of bleeding:
• INR therapeutic to 10, no bleeding: hold warfarin and give oral vitamin K 2.5–5 mg.
• Any major or life-threatening bleeding (regardless of INR): hold warfarin, give 4-factor PCC (Kcentra) and slow IV vitamin K 5–10 mg; FFP if PCC unavailable.

This client has minor bleeding (gums, small bruises) and INR 5.5. Many institutions hold warfarin and administer low-dose oral vitamin K 1–2.5 mg when minor bleeding accompanies a moderate supratherapeutic INR; some experts hold doses without vitamin K for minor bleeding plus INR

## In-depth explanation

Clinical reasoning summary
Warfarin INR-based reversal — graded approach (CHEST guideline)
Management of supratherapeutic INR depends on the INR value AND the presence/severity of bleeding:
• INR therapeutic to 10, no bleeding: hold warfarin and give oral vitamin K 2.5–5 mg.
• Any major or life-threatening bleeding (regardless of INR): hold warfarin, give 4-factor PCC (Kcentra) and slow IV vitamin K 5–10 mg; FFP if PCC unavailable.

This client has minor bleeding (gums, small bruises) and INR 5.5. Many institutions hold warfarin and administer low-dose oral vitamin K 1–2.5 mg when minor bleeding accompanies a moderate supratherapeutic INR; some experts hold doses without vitamin K for minor bleeding plus INR

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