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.

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Correct Answer is B

Explanation

Choice A reason

Weight loss is not the correct answer: Weight loss is not a common side effect of simvastatin. In fact, weight loss is generally not associated with statin use. If the client experiences significant, unintentional weight loss, it may indicate another underlying issue that should be reported to the provider.

Choice B reason:

Muscle weakness is the correct answer. The nurse should instruct the client to monitor and report any muscle weakness to the healthcare provider when taking simvastatin. Simvastatin is a statin medication used to lower cholesterol levels in the blood. While statins are generally well-tolerated, they can occasionally cause muscle-related side effects, including muscle weakness or pain.

Rhabdomyolysis, a severe condition characterized by the breakdown of muscle fibres, is a rare but serious side effect of statin use. Muscle weakness may be an early sign of this condition. Therefore, if the client experiences any unexplained or persistent muscle weakness while taking simvastatin, it should be reported to the healthcare provider immediately.

Choice C reason

Fever is not the correct answer: Fever is not a common side effect of simvastatin. If the client develops a fever while taking simvastatin, it is more likely to be related to another condition and should be reported to the provider for further evaluation.

Choice D reason:

Edema is the correct answer: Edema (swelling) is not a common side effect of simvastatin. If the client experiences significant edema, especially in the extremities, it may indicate another underlying issue that should be reported to the provider.

A. Review the need for the indwelling urinary catheter daily. B. Place the drainage bag on the bed when transporting the client. C. Use soap and water to provide perineal care. D. Encourage the client to drink 3000 mL of fluid daily. E. Change the indwelling urinary catheter tubing every 3 days. F. Empty the drainage bag when it is half-full.

Correct Answer is ["A","C"]

Explanation

A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).

B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.

C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.

D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.

E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.

F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

Correct Answer is ["A","C"]

Explanation

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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?