A nurse is reviewing the medical records of four clients.

The nurse should identify that which of the following client findings requires follow-up care?

A client who received a Mantoux test 48 hr ago and has an induration.

A client who is scheduled for a colonoscopy and is taking sodium phosphate.

A client who is taking bumetanide and has a potassium level of 3.6 mEq/L.

A client who is taking warfarin and has an INR of 1.8.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.

Choice B rationale:

Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.

Choice D rationale:

An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse should recognize the client is experiencing preterm labor due to previous preterm birth.

Preterm labor is when regular contractions begin to open the cervix before 37 weeks of pregnancy. One of the risk factors for preterm labor is having a previous preterm delivery. The client’s history indicates that her last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. The client’s current symptoms, such as lower back pain, pinkish vaginal discharge, uterine contractions and cervical dilation, also suggest that she is in preterm labor. Therefore, the nurse should recognize that the client is experiencing preterm labor due to previous preterm birth.

BMI, blood type and blood pressure are not causes of preterm labor in this case. BMI may be associated with preterm labor if it is too high or too low, but the client’s BMI is within the normal range for pregnancy. Blood type may cause Rh incompatibility if the mother is Rh negative and the baby is Rh positive, but the client’s blood type is Rh positive. Blood pressure may cause preeclampsia if it is too high, but the client’s blood pressure is normal. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, which can cause vaginal bleeding, abdominal pain and fetal distress. The client does not have these signs.

A. Allow the client to choose among a variety of activities each day. B. Give the client one simple direction at a time. C. Reinforce orientation to time, place, and person. D. Establish eye contact when communicating with the client. E. Refute the client’s delusions using logic.

Correct Answer is ["B","C","D"]

Explanation

The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.

These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.

Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.

The nurse should provide a structured and consistent daily routine for the client.

Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.

The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been admitted to the antepartum unit Complete the following sentence by using the list of options. Separate the two answers using a comma. The nurse should recognize the client is experiencing due to .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing.

A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

A charge nurse is teaching a newly licensed nurse about the facility’s computerized documentation system. Which of the following information should the nurse include?

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take

A nurse is providing teaching to an older adult client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include?

A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

A nurse is reviewing the medical records of four clients.

The nurse should identify that which of the following client findings requires follow-up care?