# The 67-year-old client with a mechanical mitral valve takes warfarin; warfarin 4 mg each evening; amiodarone was started 4 days ago for atrial fibrillation. The client reports weakness and new left flank and back pain. Blood pressure is 84/48 mm Hg, heart rate 106/min, respiratory rate 22/min, temperature 36.7°C (98.1°F), and oxygen saturation 97% on room air. Hemoglobin is 7.6 g/dL, down from 11.9 g/dL, INR is 6.8, platelets are 214,000/mm3, WBC is 8,400/mm3, and creatinine is 1.0 mg/dL. The abdomen has no visible bruising. The mechanical valve click is crisp and there is no new murmur. CT confirms an expanding left retroperitoneal hematoma. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617378&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question The 67-year-old client with a mechanical mitral valve takes warfarin; warfarin 4 mg each evening; amiodarone was started 4 days ago for atrial fibrillation. The client reports weakness and new left flank and back pain. Blood pressure is 84/48 mm Hg, heart rate 106/min, respiratory rate 22/min, temperature 36.7°C (98.1°F), and oxygen saturation 97% on room air. Hemoglobin is 7.6 g/dL, down from 11.9 g/dL, INR is 6.8, platelets are 214,000/mm3, WBC is 8,400/mm3, and creatinine is 1.0 mg/dL. The abdomen has no visible bruising. The mechanical valve click is crisp and there is no new murmur. CT confirms an expanding left retroperitoneal hematoma. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 Supratherapeutic INR without active bleeding Mechanical valve thrombosis Septic shock Warfarin-associated major hemorrhage Actions to take Select 2 Administer the prescribed IV 4-factor PCC Give the prescribed oral vitamin K 2.5 mg Administer the prescribed IV vitamin K Hold warfarin and recheck the INR in 24 hours Start a heparin infusion to protect the valve Parameters to monitor Select 2 Mechanical valve click quality Blood pressure and heart rate Temperature and WBC count Thyroid-stimulating hormone Hemoglobin level ## Explanation An expanding retroperitoneal hematoma with hypotension and a 4.3 g/dL hemoglobin fall is life-threatening major bleeding, worsened by amiodarone raising the INR. Rapid reversal requires 4-factor PCC together with IV vitamin K, which sustains the effect after PCC wears off. Hemoglobin and blood pressure with heart rate show whether bleeding and shock are controlled. ## In-depth explanation Quick answer Warfarin-associated major hemorrhage. Actions: administer the prescribed IV 4-factor PCC; administer the prescribed IV vitamin K. Monitor: blood pressure and heart rate, and hemoglobin level. Why this is correct Amiodarone inhibits warfarin metabolism, which explains the INR of 6.8. Major bleeding with hemodynamic instability requires immediate reversal: 4-factor prothrombin complex concentrate replaces factors II, VII, IX, and X within minutes, and IV vitamin K allows the liver to make new factors so the INR does not rebound. The mechanical valve raises thrombosis concern, but a life-threatening bleed takes priority, and anticoagulation is resumed later once bleeding is controlled. Easy analogy or mental picture PCC is the fire hose that puts out the fire now; IV vitamin K is the sprinkler system that keeps it from reigniting after the hose is turned off. Memory hook Bleeding and shocked on warfarin: PCC now plus vitamin K IV. NCLEX decision rule For life-threatening anticoagulant bleeding, choose rapid reversal plus sustained reversal; save management of the indication for anticoagulation until the bleeding is controlled. Why the other choices are wrong Supratherapeutic INR without bleeding is ruled out by the CT and hemoglobin fall; oral vitamin K or holding warfarin with a 24-hour recheck is correct only in that situation. Valve thrombosis would cause a muffled click or new murmur, which are absent, so valve click quality is the wrong trend. Septic shock is unlikely with a normal temperature and WBC. A heparin infusion to protect the valve is appropriate later, after bleeding is controlled, not now. TSH tracks a later amiodarone adverse effect, not the bleed. References 1DailyMed — KCENTRA (prothrombin complex concentrate, human)Indicated for urgent reversal of vitamin K antagonist in acute major bleeding, given with vitamin K. 2DailyMed — Warfarin sodium prescribing informationBleeding risk and interactions that increase INR, including amiodarone. ## Clinical scenario Case update A client with a mechanical mitral valve on warfarin and new amiodarone has INR 6.8, hypotension, a hemoglobin drop from 11.9 to 7.6 g/dL, and a CT-confirmed expanding retroperitoneal hematoma. ## Key concepts - **4-factor PCC** — Prothrombin complex concentrate containing factors II, VII, IX, and X for rapid warfarin reversal. - **Retroperitoneal hematoma** — Bleeding into the space behind the peritoneum that can hide large blood loss and cause flank pain. - **Drug interaction** — Amiodarone inhibits warfarin metabolism, raising the INR and the risk of bleeding. ## Related questions - [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. 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