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 D

Explanation

A. Incorrect. Unused medication replacement might not be necessary every 6 months and depends on the expiration date of the medication container.

B. Incorrect. Dabigatran capsules should not be crushed or opened, as it can affect the medication's efficacy and increase the risk of bleeding.

C. Incorrect. Storing the medication in the refrigerator is not necessary for dabigatran.

D. Correct. Keeping the medication in the original container helps protect it from moisture and ensures proper identification and labeling.

A. Beneficence B. Autonomy C. Fidelity D. Veracity

Correct Answer is A

Explanation

A. Correct. Beneficence refers to the ethical principle of doing good and taking actions that promote the well-being and best interests of the client. Sitting with the client to provide comfort aligns with this principle.

B. Incorrect. Autonomy relates to respecting the client's right to make decisions about their own care and treatment.

C. Incorrect. Fidelity pertains to keeping promises and maintaining trust in the nurse-client relationship.

D. Incorrect. Veracity involves truthfulness and honesty in communication with clients, particularly in providing accurate information about their care and condition.

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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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