The client is scheduled to receive Coumadin (an anticoagulant) at 9:00

The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning labora-tory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is s

1. Reassessing the client
2. Stating an expected outcome
3. Revising the nursing diagnosis
4. Modifying the nursing care plan

ANSWER

ANS: 4
The nurse is modifying the nursing care plan. Data have been updated to reflect the client’s cur-rent status of an elevated PTT; nursing diagnoses and specific interventions are revised. In this case, the revised intervention is withholding the Coumadin. By gathering further assessment data and revising nursing interventions, the nurse is modifying the nursing care plan.