# A nurse is reviewing the medication reconciliation for a 78-year-old woman who weighs 52 kg and is admitted with NSTEMI. Her past history is significant for a transient ischemic attack 18 months ago. The provider has written orders that include prasugrel 10 mg orally daily as the P2Y12 inhibitor of choice. Which action by the nurse is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374999&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A nurse is reviewing the medication reconciliation for a 78-year-old woman who weighs 52 kg and is admitted with NSTEMI. Her past history is significant for a transient ischemic attack 18 months ago. The provider has written orders that include prasugrel 10 mg orally daily as the P2Y12 inhibitor of choice. Which action by the nurse is most appropriate?

## Option

1. Administer the prasugrel as ordered because the TRITON-TIMI 38 trial excluded patients with TIA or stroke within 6 months, and this patient's event was 18 months ago; therefore, she does not meet the contraindication criteria and prasugrel is the superior antiplatelet agent for reducing ischemic events.
2. Contact the provider to clarify whether the dose should be reduced to 5 mg daily because the patient is over 75 years and weighs less than 60 kg, as the prescribing information recommends a lower maintenance dose for patients with lower body weight to reduce bleeding risk while maintaining efficacy.
3. Administer the prasugrel as prescribed and closely monitor the patient for signs of bleeding, such as bruising, hematuria, or melena, because the benefits of dual antiplatelet therapy in NSTEMI outweigh the risks even in patients with advanced age, low body weight, and remote history of transient ischemic attack.
4. Hold the prasugrel dose and notify the provider that prasugrel is contraindicated in patients with prior stroke or TIA, and use is generally not recommended in patients aged ≥75 years or weighing **✔ Correct answer**

**Correct answer: 4**

## Explanation

Prasugrel — contraindications and cautions
Prasugrel (Effient) is a thienopyridine P2Y12 inhibitor·prodrug activated mainly by hepatic esterases (less variability than clopidogrel). It is more potent and faster acting but has a higher bleeding profile. Boxed warnings and clinical guidance:

• Contraindicated in patients with a history of stroke or transient ischemic attack (TIA) — TRITON-TIMI 38 trial showed net harm (intracranial hemorrhage) in this subgroup.
• Generally NOT recommended in patients aged ≥75 years or weighing

## In-depth explanation

Clinical reasoning summary
Prasugrel — contraindications and cautions
Prasugrel (Effient) is a thienopyridine P2Y12 inhibitor·prodrug activated mainly by hepatic esterases (less variability than clopidogrel). It is more potent and faster acting but has a higher bleeding profile. Boxed warnings and clinical guidance:

• Contraindicated in patients with a history of stroke or transient ischemic attack (TIA) — TRITON-TIMI 38 trial showed net harm (intracranial hemorrhage) in this subgroup.
• Generally NOT recommended in patients aged ≥75 years or weighing

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