A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.
A client who received a Mantoux test 48 hr ago and has an induration
A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
A client who is scheduled for a colonoscopy and is taking sodium phosphate
A client who is taking warfarin and has an INR of 1.8
The Correct Answer is D
A. Induration after a Mantoux test is a common response and does not necessarily require follow-up care.
B. A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L).
C. Sodium phosphate is commonly used for bowel preparation before procedures like colonoscopy.
D. Correct. An INR of 1.8 for a client on warfarin is below the therapeutic range (usually 2.0- 3.0 for most indications), indicating that the client's blood may not be adequately anticoagulated. This requires follow-up to adjust the warfarin dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,D,A,C
Explanation
Answer:
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Review the skill level and qualifications of each AP.
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Communicate appropriate tasks to the APs with specific expectations.
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Monitor progress of task completion with each AP.
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Evaluate the APs' performance of each task.
Explanation:
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Review the skill level and qualifications of each AP: Before delegating tasks to the assistive personnel (APs), the nurse should assess their individual skills, training, and qualifications to determine their capabilities. This step ensures that tasks are assigned to the APs who are competent and trained to perform them safely and effectively.
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Communicate appropriate tasks to the APs with specific expectations: The nurse should clearly communicate the tasks to be delegated to the APs, providing specific instructions and expectations regarding how each task should be performed. This step helps prevent misunderstandings and ensures that the APs understand what is expected of them.
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Monitor progress of task completion with each AP: Once tasks are assigned, the nurse should periodically check on the progress of each AP in completing their assigned tasks. Monitoring helps the nurse ensure that tasks are being performed correctly and in a timely manner.
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Evaluate the APs' performance of each task: After the tasks are completed, the nurse should evaluate the performance of each AP. This evaluation involves assessing whether the tasks were performed according to the specific expectations communicated earlier and whether there were any issues or deviations during task completion. The evaluation helps identify areas for improvement and provides feedback for the APs to enhance their skills and performance.
Correct Answer is C
Explanation
A. Incorrect. Ensuring the device inspection sticker is current is important but not the first action to take when there's a potential safety issue.
B. Incorrect. Reporting the defect is important, but immediate action to ensure client safety should come first.
C. Correct. The nurse's first priority should be ensuring client safety. Removing the device from the room prevents any potential harm from using the device with a frayed cord.
D. Incorrect. Initiating a requisition for a replacement is important, but immediate action to ensure safety is a higher priority.
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