Question

A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?

a. "My arthritis is really bothering me because I haven't taken my aspiring in a week."
b. "My blood pressure shouldn't be high because I took my BP medication this morning."
c. "I took my warfarin last night according to my usually schedule."
d. "I will check my BP because I took a reduced dose of insulin this morning."

Answer 1

The statement about taking warfarin needs clarification because it's an anticoagulant that should usually be stopped before surgery to reduce bleeding risk.

Step-by-step explanation:

The client statement that indicates a need for further clarification by the nurse is: "I took my warfarin last night according to my usual schedule." Warfarin is an anticoagulant that can increase bleeding risk during surgery. It is typically stopped several days before surgery to reduce this risk. The nurse needs to clarify this with the client and possibly consult with the physician to confirm if the medication should have been discontinued prior to the coronary artery bypass graft (CABG) surgery.