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 ["A","C","D"]

Explanation

A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired.

B. Incorrect. While it's important to provide the client with some choices, too many options can be overwhelming and confusing.

C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia.

D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.

E. Incorrect. It's generally not effective to try to refute a client's delusions using logic.

Redirecting or validating their feelings might be more appropriate.

A. Clamp the catheter tubing for 30 min. B. Obtain a urine specimen for culture and sensitivity. C. Initiate continuous bladder irrigation. D. Administer a fluid bolus.

Correct Answer is D

Explanation

A. Incorrect. Clamping the catheter tubing might not be necessary in this situation and could potentially cause urinary retention.

B. Incorrect. While obtaining a urine specimen might be necessary if there's suspicion of infection, the immediate concern in this case is the low urine output rather than infection. Therefore, this may not be the first action taken.

C. Incorrect. Continuous bladder irrigation might be indicated for specific situations, such as after certain surgeries, but it is not the first-line intervention based solely on the description provided.

D. Incorrect. Administering a fluid bolus might not be necessary unless there are other signs of dehydration or fluid imbalance.

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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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