A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?

This is because the first priority for the nurse is to assess the cause of the vomiting and ensure that the NG tube is working properly. If the suction device is malfunctioning, it could lead to gastric distension, nausea and vomiting. The nurse should check the suction settings, tubing, canister and connections for any problems.

Choice A is wrong because replacing the NG tube is not the first action to take.

The nurse should first rule out other causes of vomiting before attempting to reinsert the tube, which could be uncomfortable and risky for the client.

Choice B is wrong because providing oral hygiene care is not the most urgent action to take.

While oral hygiene care is important for comfort and infection prevention, it does not address the underlying cause of vomiting or prevent further complications.

Choice C is wrong because administering an antiemetic medication is not the most appropriate action to take.

The nurse should first identify the cause of vomiting and correct it if possible.

Giving an antiemetic medication without resolving the problem could mask symptoms and delay treatment.

The correct answer is choice D: A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

A Mantoux test with an induration after 48 hours can be a normal reaction, especially if the induration is within the expected size range for a positive result, depending on the individual’s risk factors and history. It does not necessarily require follow-up care unless the induration is significantly large or there are other concerning symptoms.

Choice B rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not typically require follow-up care for the sodium phosphate intake itself. Sodium phosphate is commonly used as a bowel prep medication to clear the intestines prior to the procedure.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L), so a client taking bumetanide with this potassium level would not typically require follow-up care for the potassium level alone.

Choice D rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care because the therapeutic range for warfarin is typically between 2.0 and 3.0 for most indications. An INR of 1.8 may indicate that the blood is not “thin” enough, increasing the risk of thrombotic events, and the warfarin dose may need adjustment.