A nurse is reviewing the medical records of four clients.
The nurse should identify that which of the following client findings requires follow-up care.
A client who received a Mantoux test 48 hr ago and has an induration.
A client who is scheduled for a colonoscopy and is taking sodium phosphate.
A client who is taking bumetanide and has a potassium level of 3.6 mEq/L.
A client who is taking warfarin and has an INR of 1.8.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because the AP’s statement constitutes an intentional tort, which is a wrong that the defendant knew or should have known would be caused by their actions. An assault is defined as intentionally putting another person in reasonable apprehension of an imminent harmful or offensive contact.
The AP’s threat of using restraints and force-feeding the client could cause the client to fear for their safety and dignity, which is an assault.
Choice B is wrong because Battery is wrong because battery is defined as intentional causation of harmful or offensive contact with another person without that person’s consent.
The AP did not actually touch the client or carry out the threat, so there was no battery.
Choice C is wrong because Negligence is wrong because negligence is an unintentional tort, which occurs when the defendant’s actions or inactions were unreasonably unsafe.
The AP did not act or fail to act in a way that breached the standard of care or caused harm to the client, so there was no negligence.
Choice D is wrong because Malpractice is wrong because malpractice is a type of negligence that involves a professional failing to perform their duties according to the standards of their profession.
The AP did not perform any professional duty or service that was below the standard of care or caused harm to the client, so there was no malpractice.
Correct Answer is A
Explanation
A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.
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