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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Hematuria is the presence of red blood cells in the urine, which can make it appear pink or cola-colored. Hematuria is a common sign of glomerulonephritis, which is inflammation of the tiny filters in the kidneys (glomeruli) that remove waste and excess fluid from the blood. Hematuria occurs because the inflamed glomeruli allow some blood cells to leak into the urine.

Choice B is wrong because polyuria is the production of abnormally large amounts of urine. Polyuria is not a typical feature of acute glomerulonephritis, which may actually cause reduced urine output due to fluid retention and decreased kidney function.

Choice C is wrong because weight loss is not a common symptom of acute glomerulonephritis. On the contrary, weight gain may occur due to fluid retention and edema (swelling) in the face, hands, feet and abdomen.

Choice D is wrong because hypotension is low blood pressure. Hypotension is not usually associated with acute glomerulonephritis, which may cause high blood pressure (hypertension) due to fluid overload and impaired sodium excretion by the kidneys.

Normal ranges for blood pressure are less than 120/80 mmHg for adults. Normal ranges for urine output are about 800 to 2000 mL per day for adults.

Normal ranges for protein in the urine are less than 150 mg per day for adults. Normal ranges for red blood cells in the urine are less than 3 per high-power field for men and less than 5 per high-power field for women.

A. Allow the client to choose among a variety of activities each day. B. Give the client one simple direction at a time. C. Reinforce orientation to time, place, and person. D. Establish eye contact when communicating with the client.

Correct Answer is ["B","C","D"]

Explanation

The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.

These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.

Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.

The nurse should provide a structured and consistent daily routine for the client.

Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.

The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.

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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.

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Explanation

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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.