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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Ketorolac is incorrect because it is an NSAID that is used for short-term pain relief. It has a higher risk of causing irritation to the stomach lining and is not recommended for clients with a history of peptic ulcers.
Choice B reason:
Acetaminophen is the correct answer. When caring for a client who reports a headache and has a history of a peptic ulcer, the nurse should administer Acetaminophen. Acetaminophen is an analgesic (pain reliever) and antipyretic (fever reducer) that does not have anti-inflammatory properties. It is a suitable option for pain relief in clients with a history of peptic ulcers because it is less likely to cause irritation to the stomach lining compared to nonsteroidal anti-inflammatory drugs (NSAIDs).
Choice C reason
Aspirin is not appropriate: Aspirin is an NSAID with anti-inflammatory, analgesic, and antipyretic properties. Like other NSAIDs, it can increase the risk of stomach irritation and should be avoided in clients with a history of peptic ulcers.
Choice D reason:
Ibuprofen is not the right option: Ibuprofen is another NSAID commonly used for pain relief and reducing inflammation and fever. Like other NSAIDs, it can irritate the stomach lining and is not recommended for clients with a history of peptic ulcers.
Correct Answer is B
Explanation
The correct answer is choice B. Use an ibuterol inhaler.
Choice A rationale:
Completing oral hygiene is important for overall health, but it is not specifically related to the preparation for postural drainage in cystic fibrosis patients. Postural drainage is a technique used to clear mucus from the lungs, and oral hygiene does not directly affect this process.
Choice B rationale:
Using a bronchodilator, such as an ibuterol inhaler, is recommended before postural drainage because it helps to open the airways, making the drainage process more effective. Bronchodilators are often used to relax the muscles around the airways, which can become constricted in conditions like cystic fibrosis.
Choice C rationale:
Taking pancrelipase is related to aiding digestion in cystic fibrosis patients who have pancreatic insufficiency. While it is an important part of the overall management of cystic fibrosis, it is not directly related to the preparation for postural drainage.
Choice D rationale:
Eating a meal before postural drainage is not recommended because a full stomach can make the process uncomfortable and less effective. It is generally advised to perform postural drainage on an empty stomach to ensure that the mucus can be cleared from the lungs more easily.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.