# A 67-year-old client with a mechanical mitral valve takes warfarin and recently started amiodarone. The client has BP 84/48 mm Hg, hemoglobin 7.6 g/dL from 11.9 g/dL, INR 6.8, and an expanding retroperitoneal hematoma. Place the medication-safety actions in order from emergency recognition through the early post-hemostasis plan.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522051&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 67-year-old client with a mechanical mitral valve takes warfarin and recently started amiodarone. The client has BP 84/48 mm Hg, hemoglobin 7.6 g/dL from 11.9 g/dL, INR 6.8, and an expanding retroperitoneal hematoma. Place the medication-safety actions in order from emergency recognition through the early post-hemostasis plan.

Administer authorized 4-factor PCC with vitamin K and prescribed blood products while source control proceeds.

Reassess hemodynamics, hemoglobin, INR, renal function, hematoma progression, and adverse effects.

Activate the major-bleeding response, hold warfarin, and support airway, breathing, circulation, and perfusion.

Obtain and time-stamp the ordered blood count, INR, metabolic panel, type and crossmatch, and medication history.

Convene the valve, bleeding, pharmacy, and prescriber teams to document when and how anticoagulation will be resumed.

## Explanation

Immediate stabilization and warfarin hold come first, followed by rapid data collection, reversal with source control, response assessment, and an explicit interdisciplinary restart plan.

## In-depth explanation

Quick answer
Sequence stabilize, measure, reverse, reassess, and plan.

Why this is correct
The workflow must control life-threatening bleeding without losing the mechanical-valve indication. Current laboratory data and medication timing support reversal, and response data support the later restart decision.

Easy analogy or mental picture
First stop the flooding, then measure and repair it, check the repair, and plan how to protect the valve again.

Memory hook
Stabilize, measure, reverse, reassess, restart-plan.

NCLEX decision rule
The restart decision follows hemostasis evidence; it does not precede emergency bleeding control.

Why the other choices are wrong
Delaying stabilization for consultation or restarting before hemostasis can create avoidable harm.References
1DailyMed: Warfarin SodiumMajor bleeding, INR monitoring, pregnancy and mechanical-valve risk, and therapy individualization
2DailyMed: KCENTRAUrgent VKA reversal for acute major bleeding with concurrent vitamin K
3ACC/AHA 2020 Valvular Heart Disease GuidelineVKA therapy for mechanical valves, pregnancy counseling, and monitored anticoagulation planning

## Clinical scenario

Closed-loop major-bleed workflow
Sequence stabilization, decision-changing laboratory data, authorized reversal and source control, response assessment, and an accountable mechanical-valve anticoagulation restart plan.

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