# A nurse is caring for a patient who has been prescribed warfarin therapy. Which assessment finding would require the nurse to take immediate action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543589 > language: ko > subject: Next Gen NCLEX ## 문제 A nurse is caring for a patient who has been prescribed warfarin therapy. Which assessment finding would require the nurse to take immediate action? ## 보기 1. Black, tarry stools and a hemoglobin level of 7.2 g/dL **✔ 정답** 2. INR level of 2.8 with no signs of bleeding 3. Bruising on the arms and legs from minor trauma 4. Gum bleeding when brushing teeth **정답: 1** ## 해설 Black, tarry stools with low hemoglobin indicate active GI bleeding, a life-threatening complication of warfarin requiring immediate action. Other findings are less urgent. ## 심화 해설 Clinical Priority Analysis The correct answer is option 1: Black, tarry stools and a hemoglobin level of 7.2 g/dL. This combination of findings signals an active, potentially life-threatening gastrointestinal (GI) hemorrhage requiring immediate nursing action. Pathophysiology and Clinical Reasoning Warfarin exerts its anticoagulant effect by inhibiting vitamin K epoxide reductase, thereby reducing the synthesis of functional clotting factors II, VII, IX, and X. A major adverse effect of this therapy is bleeding, with the GI tract being a common site. The presence of melena (black, tarry stools) indicates that blood has been exposed to digestive enzymes and gastric acid, confirming an upper GI source of bleeding [1]. A hemoglobin of 7.2 g/dL represents a significant drop from normal values (typically 12-16 g/dL for females and 14-18 g/dL for males), indicating a substantial loss of red blood cell mass. This level is below the commonly accepted transfusion threshold of 7-8 g/dL in many clinical guidelines, signifying that the patient's oxygen-carrying capacity is critically compromised. The combination of ongoing blood loss and severe anemia can rapidly progress to hypovolemic shock, as evidenced by case reports where patients with warfarin-associated upper GI bleeding presented with hypotension and tachycardia alongside a hemoglobin of 6.8 g/dL [1]. This scenario demands immediate assessment of hemodynamic stability, notification of the provider, preparation for potential blood transfusion, and administration of vitamin K or other reversal agents as ordered. Analysis of Incorrect Options - Option 2: An INR of 2.8 without bleeding signs is a therapeutic level for many indications, such as atrial fibrillation or venous thromboembolism, where the target range is typically 2.0-3.0. While this requires monitoring, it does not represent an immediate threat in the absence of active hemorrhage. - Option 3: Bruising (ecchymosis) on the extremities from minor trauma is a common and expected sign of anticoagulation. It indicates a heightened bleeding tendency but is not an acute, life-threatening event. The nurse's action would be patient education on safety and monitoring, not an emergency response. - Option 4: Gum bleeding when brushing teeth is a minor mucocutaneous bleed. While it warrants evaluation of the INR and reinforcement of gentle oral care, it does not pose the immediate risk of hemodynamic instability that a major GI hemorrhage does. NCLEX-RN Application: Prioritization and Triage This question tests the critical nursing skill of prioritizing care using a framework like the ABCs (Airway, Breathing, Circulation) and the concept of "acute versus chronic." Active GI bleeding with a critically low hemoglobin directly threatens the "C" (Circulation) component, placing the patient at high risk for decompensation. Research confirms that non-variceal upper GI bleeding in patients on antithrombotic therapy remains a major clinical emergency with significant morbidity . The nurse must recognize that melena is not an isolated symptom but a marker of a dynamic, ongoing process. Furthermore, the risk of such bleeding is a well-documented complication of oral anticoagulation, and its management is a high-priority nursing intervention . A non-traumatic muscle hematoma, while serious, illustrates that bleeding can occur in various locations; however, a GI bleed with a hemoglobin of 7.2 g/dL represents a more immediate threat to circulating volume and perfusion than a contained hematoma or superficial bleeding . The nurse's immediate actions must focus on stabilizing the patient's circulatory status.References (research sources) - [1]Persistent Anticoagulation and Severe Upper Gastrointestinal Bleeding in a Patient With Factor V Leiden: A Case of the Warfarin Reservoir Phenomenon.Case reportKammawal Y. (2025) · DOI: 10.7759/cureus.91638 ## 임상 시나리오 Warfarin-Induced GI Bleed: Emergency RecognitionPrioritizing Active Hemorrhage with Hemodynamic Compromise The combination of melena and a critically low hemoglobin of 7.2 g/dL confirms an active, major upper GI bleed. This level is below the common transfusion threshold of 7-8 g/dL and indicates severely compromised oxygen-carrying capacity. Immediate nursing actions include assessing for signs of hypovolemic shock such as hypotension and tachycardia, ensuring large-bore IV access, and preparing for urgent blood transfusion. The provider must be notified immediately. CautionDo not confuse a supratherapeutic INR alone with an emergency. An INR of 2.8 is often therapeutic. The presence of active bleeding with hemodynamic instability, not just the lab value, dictates the urgency. ## 핵심 개념 - **Melena** — Black, tarry stools caused by the digestion of blood in the GI tract, indicating an upper gastrointestinal bleed. - **Warfarin** — An oral anticoagulant that inhibits vitamin K-dependent clotting factors (II, VII, IX, X) to prevent thromboembolism. - **Hemoglobin** — A protein in red blood cells that carries oxygen; a level of 7.2 g/dL indicates severe anemia and compromised oxygen delivery. - **INR (International Normalized Ratio)** — A laboratory test used to monitor warfarin therapy and measure the extrinsic pathway of coagulation. - **Hypovolemic Shock** — A life-threatening condition resulting from rapid fluid or blood loss, leading to inadequate tissue perfusion. ## 같은 주제 문제 - [A nurse is caring for a patient who has been receiving continuous intravenous heparin ther…](https://mymerci.kr/pages/nclex_q.php?qn_id=543584) - [A nurse is caring for a patient who has been receiving continuous IV morphine for pain man…](https://mymerci.kr/pages/nclex_q.php?qn_id=543585) - [A nurse is caring for a 68-year-old client who underwent total hip replacement surgery 2 d…](https://mymerci.kr/pages/nclex_q.php?qn_id=543586) - [A nurse is caring for a 68-year-old patient with chronic obstructive pulmonary disease (CO…](https://mymerci.kr/pages/nclex_q.php?qn_id=543587) - [A nurse is caring for a patient who has been receiving continuous IV heparin therapy for d…](https://mymerci.kr/pages/nclex_q.php?qn_id=543588) - [A nurse is caring for a 68-year-old patient with chronic obstructive pulmonary disease (CO…](https://mymerci.kr/pages/nclex_q.php?qn_id=543590) - [A nurse is caring for a 72-year-old patient who underwent total hip replacement surgery 2 …](https://mymerci.kr/pages/nclex_q.php?qn_id=543591) - [A nurse is caring for a 50-year-old patient who has been admitted with acute pancreatitis.…](https://mymerci.kr/pages/nclex_q.php?qn_id=543592) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._