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 taking warfarin and has an INR of 1.8.
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.
The Correct Answer is B
Choice A rationale:
A client who received a Mantoux test 48 hr ago and has an induration does not require immediate follow-up care. An induration at the injection site indicates a positive reaction, but further evaluation and management are necessary, not urgent.
Choice B rationale:
A client taking warfarin with an INR of 1.8 requires follow-up care. The normal range for INR in a client taking warfarin is usually 2.0 to 3.0. An INR of 1.8 suggests inadequate anticoagulation, putting the client at risk of thromboembolic events. Dose adjustment or other interventions are needed to bring the INR within the therapeutic range.
Choice C rationale:
A client scheduled for a colonoscopy and taking sodium phosphate does not necessarily require immediate follow-up care. However, sodium phosphate can cause electrolyte imbalances, so monitoring for any signs of electrolyte disturbances is essential, but it does not mandate urgent intervention.
Choice D rationale:
A client taking bumetanide with a potassium level of 3.6 mEq/L requires follow-up care. The normal range for potassium is typically 3.5 to 5.0 mEq/L. A potassium level below the normal range (hypokalemia) can lead to cardiac arrhythmias and muscle weakness. The client may need potassium supplements or dietary adjustments to correct the imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Belching is a common finding following an esophagogastroduodenoscopy and is not a cause for concern unless it is excessive or accompanied by other concerning symptoms.
Choice B rationale:
(Correct Choice) Abdominal pain after an esophagogastroduodenoscopy can indicate complications such as perforation, bleeding, or infection. It is essential to report this finding to the provider promptly for further evaluation and management.
Choice C rationale:
Sore throat is a common and expected side effect after the procedure due to irritation from the endoscope. It usually resolves on its own and does not require immediate reporting unless it worsens or is associated with other concerning symptoms.
Choice D rationale:
Flatulence is not typically related to an esophagogastroduodenoscopy and is not a cause for concern in this context.
Correct Answer is D
Explanation
The correct answer is choice D: Insert an IV saline lock.
Choice D rationale: Inserting an IV saline lock is an appropriate nursing intervention for a client with a tonic-clonic seizure. This allows for quick access to administer intravenous medications, such as anticonvulsants, in case the client experiences another seizure.
Choice A rationale: Providing a tracheostomy tray at the bedside is not necessary for seizure precautions. While maintaining a patent airway is essential during a seizure, it can typically be managed with proper positioning and suctioning if necessary.
Choice B rationale: Placing the client in a supine position is not recommended for seizure precautions. Instead, the client should be placed in a semi-prone or lateral position to promote drainage of secretions and prevent aspiration.
Choice C rationale: Placing a plastic tongue depressor at the client's bedside is not an appropriate intervention. Attempting to insert an object into the client's mouth during a seizure can cause injury and is not recommended.
In summary, the nurse should include inserting an IV saline lock as part of the plan of care for a client who has experienced a tonic-clonic seizure. This will allow for rapid administration of medications, if necessary, while prioritizing client safety and adhering to seizure precautions.
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