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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Varicella vaccine is typically administered to children at the age of 1 year, not at 2 months. The first dose of varicella vaccine is usually given at 12-15 months of age, with a second dose recommended at 4-6 years of age.

Choice B rationale:

Rotavirus vaccine is recommended to be administered to infants at the age of 2 months. It is an oral vaccine that protects against rotavirus infections, a common cause of severe diarrhea and dehydration in infants and young children.

Choice C rationale:

Influenza vaccine is not typically administered to infants at 2 months of age. Influenza vaccination is recommended annually for children older than 6 months.

Choice D rationale:

Hepatitis A vaccine is not routinely given at 2 months of age. Hepatitis A vaccination is typically recommended starting at 1 year of age, with a second dose administered 6-18 months later.

A. Acetaminophen B. Ibuprofen C. Naproxen sodium D. Aspirin

Correct Answer is A

Explanation

A. Correct. Acetaminophen can be taken concurrently with enoxaparin without significant interactions or increased bleeding risk.

B. Incorrect. Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution in combination with anticoagulants due to an increased risk of bleeding.

C. Incorrect. Naproxen sodium, like other NSAIDs, should be used cautiously with anticoagulants due to potential interactions and bleeding risk.

D. Incorrect. Aspirin is an anticoagulant itself and can increase the risk of bleeding when taken with enoxaparin.

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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.

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Naxlex Comprehensive Predictor Exams

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