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 C
Explanation
A. While additional staffing might be necessary, the nurse's priority in a mass casualty event is to assess and provide care to incoming clients.
B. Discharging specific acute care clients may not be the immediate priority in a mass casualty event.
C. Correct. In a mass casualty event, the nurse should collaborate with the emergency department to determine the medical needs and prioritize care for incoming clients.
D. Acting as a liaison between the facility and the media may not be the immediate priority during a mass casualty event.
Correct Answer is C
Explanation
Choice A rationale:
Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.
Choice B rationale:
Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.
Choice C rationale:
Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.
Choice D rationale:
Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.
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