A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting warfarin? (Select all that apply.)

Choice A reason: Saw palmetto can potentiate the effects of anticoagulants like warfarin by inhibiting platelet aggregation. This increases the risk of bleeding, which is dangerous when combined with warfarin’s anticoagulant properties. Discontinuation is advised to prevent hemorrhagic complications. Choice B reason: Glucosamine is primarily used for joint health and does not have a significant effect on coagulation. Although some anecdotal reports suggest minor interactions, it is not a known potentiator of warfarin and does not need to be discontinued unless otherwise directed by a provider. Choice C reason: Black cohosh has estrogen-like effects and may interfere with coagulation pathways. It can increase the risk of bleeding when taken with warfarin, making it unsafe for concurrent use. Discontinuation is necessary to prevent adverse interactions. Choice D reason: Flaxseed oil contains omega-3 fatty acids, which have mild antiplatelet effects. However, the interaction with warfarin is not strong enough to warrant routine discontinuation unless taken in high doses. It is not considered a primary concern. Choice E reason: Gingko biloba is well-documented to increase bleeding risk due to its antiplatelet activity. When combined with warfarin, the risk of serious bleeding events rises significantly. It should be discontinued before initiating warfarin therapy.