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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B: Dyspnea.

Choice B rationale: Dyspnea, or difficulty breathing, is a potential indication of a recurrent pulmonary embolism and should be reported immediately. Early detection and intervention are crucial to prevent life-threatening complications.

Choice A rationale: Hypotension may be a concerning finding in postoperative clients, but it is not the priority for a client with a history of pulmonary embolism. Hypotension could be related to various factors like bleeding or anesthesia effects.

Choice C rationale: Dry cough may occur as a result of irritation or inflammation in the airway due to the surgical procedure or anesthesia. Although it should be monitored, it is not the highest priority in this situation.

Choice D rationale: Tachycardia can be a common postoperative finding due to pain, anxiety, or other factors. Although it should be monitored and addressed, it is not the most critical concern in this case. Dyspnea is more closely related to a possible pulmonary embolism and should be reported promptly.

A. Sticks his tongue out. B. Frowns symmetrically. C. Identifies a sour taste. D. Shrugs his shoulders.

Correct Answer is D

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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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?