# A 72-year-old client on chronic warfarin (target INR 2.0–3.0) is brought to the ED after a fall down the stairs. The client has a large scalp laceration, decreased level of consciousness, and a head CT showing acute intracranial hemorrhage. Vital signs: BP 168/96, HR 102, RR 22. Stat INR is 3.8. Which set of orders does the nurse anticipate as the priority for urgent reversal? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=374953&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## Question A 72-year-old client on chronic warfarin (target INR 2.0–3.0) is brought to the ED after a fall down the stairs. The client has a large scalp laceration, decreased level of consciousness, and a head CT showing acute intracranial hemorrhage. Vital signs: BP 168/96, HR 102, RR 22. Stat INR is 3.8. Which set of orders does the nurse anticipate as the priority for urgent reversal? ## Option 1. Hold warfarin and administer 4-factor prothrombin complex concentrate (PCC, Kcentra) per weight-based protocol PLUS slow IV vitamin K (phytonadione) 5–10 mg, with continuous monitoring; FFP is acceptable if PCC is unavailable. **✔ Correct answer** 2. Hold warfarin and give a single oral dose of vitamin K (phytonadione) 1–2.5 mg, then recheck the INR after 24 hours; this approach is recommended per American College of Chest Physicians guidelines for INR 3.5–4.5 in nonbleeding patients. 3. Administer protamine sulfate 25 mg IV over 10 minutes as a reversal agent for warfarin; protamine binds to warfarin directly and neutralizes its anticoagulant effect, and is the reversal agent of choice for warfarin in emergency settings. 4. Continue the current warfarin dose, maintain the client in a supine position with head of bed at 30 degrees, and perform serial neurological checks every 4 hours to monitor for worsening hemorrhage. **Correct answer: 1** ## Explanation Warfarin-related life-threatening hemorrhage — emergency reversal Intracranial hemorrhage on warfarin is a true emergency. INR alone is misleading — even a value within target range can accompany life-threatening bleeding when the patient has anticoagulant on board. Standard guideline-based reversal: (1) Hold all anticoagulants/antiplatelets immediately. (2) 4-factor PCC (Kcentra) is preferred over FFP because it acts within minutes, requires small volume (~100 mL), and replaces factors II, VII, IX, X plus protein C and S. Dose is INR-guided per weight (e.g., 25 IU/kg for INR 2-3.9, 35 IU/kg for INR 4-6, 50 IU/kg for INR >6, max 5000 IU). FFP is used only if PCC is unavailable (slower onset, large volume, fluid overload risk). (3) Slow IV vitamin K 5-10 mg co-administered to provide sustained reversal. Vitamin K corrects more slowly (12-24 h) but prevents INR rebound after PCC wears off. Push too fast risks anaphylactoid reaction — give over ≥30 minutes diluted. (4) Continuous monitoring: ECG, BP, repeat neuro exam, and recheck INR after PCC. (5) Concurrent supportive care: neurosurgery consult, blood pressure control, head-of-bed positioning per neuro guidance, seizure precautions, definitive surgical management as indicated. Other choices: • Option 2 (hold + low-dose oral vitamin K + 24-h recheck) is appropriate for asymptomatic supratherapeutic INR, NOT life-threatening hemorrhage. • Option 4 (continue warfarin, observe) is dangerous — bleeding will progress. • Option 3 (protamine sulfate) reverses HEPARIN, not warfarin. Confusing the two is a high-frequency NCLEX trap. ## In-depth explanation Clinical reasoning summary Warfarin-related life-threatening hemorrhage — emergency reversal Intracranial hemorrhage on warfarin is a true emergency. INR alone is misleading — even a value within target range can accompany life-threatening bleeding when the patient has anticoagulant on board. Standard guideline-based reversal: (1) Hold all anticoagulants/antiplatelets immediately. (2) 4-factor PCC (Kcentra) is preferred over FFP because it acts within minutes, requires small volume (~100 mL), and replaces factors II, VII, IX, X plus protein C and S. Dose is INR-guided per weight (e.g., 25 IU/kg for INR 2-3.9, 35 IU/kg for INR 4-6, 50 IU/kg for INR >6, max 5000 IU). FFP is used only if PCC is unavailable (slower onset, large volume, fluid overload risk). (3) Slow IV vitamin K 5-10 mg co-administered to provide sustained reversal. Vitamin K corrects more slowly (12-24 h) but prevents INR rebound after PCC wears off. Push too fast risks anaphylactoid reaction — give over ≥30 minutes diluted. (4) Continuous monitoring: ECG, BP, repeat neuro exam, and recheck INR after PCC. (5) Concurrent supportive care: neurosurgery consult, blood pressure control, head-of-bed positioning per neuro guidance, seizure precautions, definitive surgical management as indicated. Other choices: • Option 1 (hold + low-dose oral vitamin K + 24-h recheck) is appropriate for asymptomatic supratherapeutic INR, NOT life-threatening hemorrhage. • Option 2 (continue warfarin, observe) is dangerous — bleeding will progress. • Option 4 (protamine sulfate) reverses HEPARIN, not warfarin. Confusing the two is a high-frequency NCLEX trap. ## Related questions - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=en) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=en) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=en) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=en) - [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=en) - [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=374953&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=374953&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=374953&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=374953&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=374953&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._