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 {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
Pyrexia, also known as fever, refers to an elevated body temperature that is above the normal range. The normal body temperature is typically around 37°C (98.6°F), and a temperature of 38.4°C (101.1°F) indicates a fever.
Alternative Choices:
1. "tachycardia" due to "heart rate of 92/min"
- Incorrect. Tachycardia refers to an abnormally high heart rate, usually above 100 beats per minute (bpm) in adults. A heart rate of 92/min is within normal limits and does not qualify as tachycardia.
2. "hypertension" due to "blood pressure of 130/78 mm Hg"
- Incorrect. Hypertension is defined as having a blood pressure reading consistently above 140/90 mm Hg. The reading of 130/78 mm Hg falls into the elevated category but does not reach the threshold for hypertension.
3. "respiratory distress" due to "respiratory rate of 18/min"
- Incorrect. A respiratory rate of 18 breaths per minute is considered normal for adults, so this finding does not indicate respiratory distress.
4. "obesity" due to "current BMI of 29.9"
- Partially correct. A BMI of 29.9 places the client in the "overweight" category, just below the threshold for obesity (BMI of 30 or higher). However, the presence of pyrexia is the more immediate clinical concern based on the provided vital signs.
Correct Answer is C
Explanation
A. Incorrect. While the nurse is curious about the client's reasons, it may come across as intrusive or defensive.
B. Incorrect. Making an assumption about the client's potential benefit is not appropriate. The client has the right to access their own records.
C. Correct. This response is respectful of the client's request while also explaining the limitation related to therapist notes.
D. Incorrect. The about the client's happiness with treatment is not directly related to their request for therapist notes.
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