# A 67-year-old client with a mechanical mitral valve takes warfarin. Four days after amiodarone was started, the client develops weakness, new flank and back pain, BP 84/48 mm Hg, hemoglobin 7.6 g/dL from 11.9 g/dL, and INR 6.8. Classify each finding by the medication decision it supports. More than one column may apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522048&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 67-year-old client with a mechanical mitral valve takes warfarin. Four days after amiodarone was started, the client develops weakness, new flank and back pain, BP 84/48 mm Hg, hemoglobin 7.6 g/dL from 11.9 g/dL, and INR 6.8. Classify each finding by the medication decision it supports. More than one column may apply.

|  | Supports active major bleeding | Supports excessive warfarin effect | Supports continuing thrombotic indication |
| --- | --- | --- | --- |
| Hemoglobin decreased from 11.9 to 7.6 g/dL |  |  |  |
| Blood pressure is 84/48 mm Hg with weakness |  |  |  |
| INR is 6.8 |  |  |  |
| Amiodarone was started 4 days ago |  |  |  |
| The client has a mechanical mitral valve |  |  |  |

## Explanation

The hemoglobin fall and hypotension support active major bleeding; INR 6.8 and recent amiodarone support excessive anticoagulant effect; the mechanical mitral valve supports a continuing high-risk anticoagulation indication.

## In-depth explanation

Quick answer
Sort cues into bleeding severity, excessive anticoagulant effect, and thrombotic indication.

Why this is correct
Warfarin harm cannot be judged from INR alone. Hemodynamics and hemoglobin establish severity, recent interacting therapy explains the excessive effect, and the mechanical valve explains why the post-bleed plan requires specialist coordination.

Easy analogy or mental picture
Use three folders: how badly the client is bleeding, why anticoagulation intensified, and why clot prevention still matters.

Memory hook
Bleed, interaction, indication: keep all three visible.

NCLEX decision rule
Analyze each cue by the immediate or later medication decision it changes.

Why the other choices are wrong
Normal oxygen saturation and no external bruising cannot exclude a retroperitoneal hemorrhage.References
1DailyMed: Warfarin SodiumMajor bleeding, INR monitoring, pregnancy and mechanical-valve risk, and therapy individualization
2DailyMed: Amiodarone HydrochlorideWarfarin potentiation, serious bleeding risk, dose review, and close prothrombin-time monitoring
3ACC/AHA 2020 Valvular Heart Disease GuidelineVKA therapy for mechanical valves, pregnancy counseling, and monitored anticoagulation planning

## Clinical scenario

Independent cue analysis
Separate evidence of major bleeding, excessive warfarin exposure, and the continuing thrombotic indication so the immediate and post-hemostasis plans are both visible.

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