Certified Medical-Surgical Registered Nurse Practice Test

Attempts to revascularize Mr. Palmer's leg are unsuccessful, and he has a below-knee amputation (BKA) of his right extremity. Which monitoring is essential for the nurse due to Mr. Palmer's history of warfarin sodium (Coumadin) daily?

1. Limit his intake of foods high in vitamin K.

2. Check the femoral puncture site at frequent intervals.

3. Observe signs of pulmonary embolism.

4. Monitor his prothrombin time.

The correct answer is: Check the femoral puncture site at frequent intervals.

Monitoring the femoral puncture site at frequent intervals is essential for the nurse due to Mr. Palmer's history of warfarin sodium (Coumadin) daily because Warfarin is an anticoagulant medication that works by reducing the body's ability to form blood clots. This increases the risk of bleeding, which is a concern following any surgical procedure, especially an amputation. By checking the femoral puncture site frequently, the nurse can assess for any signs of bleeding or hematoma formation that may require immediate intervention to prevent complications. While it is important to monitor the prothrombin time in patients taking Warfarin to assess their anticoagulation status, in this particular scenario, monitoring the femoral puncture site takes precedence due to the immediate post-operative period following a below-knee amputation and the increased risk of bleeding at the surgical site. Limiting the intake of foods high in vitamin K is typically recommended for patients on Warfarin to maintain stable anticoagulation levels, but it is not the priority in this situation. Observing signs of pulmonary embolism is important in any patient following surgery, but it is not specifically related to Mr. Palmer's history of Warfarin use and BKA.