A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.

Which of the following actions should the nurse perform first?

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

Choice A rationale:

An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.

Choice B rationale:

Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.

Choice D rationale:

An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.

Choice A reason:

Substitute tobacco use with an electronic cigarette Electronic cigarette, also known as e-cigarettes or vapes, are not recommended as a primary treatment for nicotine withdrawal. While they may be considered less harmful than traditional tobacco products, their long-term safety and effectiveness in helping individuals quit smoking are still a subject of debate and research. It is generally better to opt for proven nicotine replacement therapies, such as nicotine gum, patches, lozenges, or other medications approved by healthcare providers for smoking cessation.

Choice B reason:

Limitin use of nicotine gum to 6 months is the correct choice. When discussing treatment options with a client experiencing nicotine withdrawal, the nurse should include the information that the use of nicotine gum should be limited to 6 months. Nicotine gum is a form of nicotine replacement therapy (NRT) used to help individuals quit smoking by reducing withdrawal symptoms and cravings.

However, prolonged use of nicotine gum can lead to its own dependence on nicotine, which is counterproductive to the goal of quitting smoking altogether. The use of NRT is typically recommended for a limited duration, and the goal is to gradually reduce the dosage over time until the individual can comfortably quit nicotine use altogether.

Choice C reason:

Using progressively larger nicotine patches Using progressively larger nicotine patches is not a recommended approach for nicotine withdrawal. Nicotine patches are available in different strengths, and the appropriate dosage should be determined based on the individual's smoking history and nicotine dependence. Starting with the appropriate strength and gradually reducing the dosage over time is the preferred approach to help clients quit smoking.

Choice D reason:

Using up to 40 nicotine lozenges per day the use of nicotine lozenges should be guided by the instructions provided with the product or as prescribed by a healthcare provider. It is not advisable to exceed the recommended dosage. Using excessive amounts of nicotine lozenges or any other NRT product can lead to nicotine toxicity and other adverse effects.