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 A

Explanation

A. Instruct the client to abstain from sexual intercourse for 1 month. B. Administer ceftriaxone via intermittent IV bolus. C. Schedule the client for retesting in 1 week. D. Report the infection to the state department of health.

Correct Answer is D

Explanation

Choice A rationale:

Instructing the client to abstain from sexual intercourse for one month is not necessary for the management of Chlamydia trachomatis. Instead, the client should be advised to abstain from sexual activity until they and their partner(s) have completed the prescribed course of antibiotics and are no longer contagious, which is usually within 7 days.

Choice B rationale:

Administering ceftriaxone via intermittent IV bolus is not the recommended route for treating Chlamydia trachomatis. The standard treatment for Chlamydia trachomatis infection is oral antibiotics, such as azithromycin or doxycycline. Intravenous administration is not typically required for uncomplicated cases.

Choice C rationale:

Scheduling the client for retesting in one week is not necessary if the client has received appropriate treatment and follows the prescribed course of antibiotics. Retesting is generally recommended 3 months after treatment, especially in cases of persistent or recurrent symptoms.

Choice D rationale:

Reporting the infection to the state department of health is a crucial action. Chlamydia trachomatis is a reportable sexually transmitted infection in many jurisdictions. Reporting helps public health authorities track the incidence of the disease, implement preventive measures, and allocate resources effectively to control its spread within the community. It is essential for the nurse to comply with legal and ethical obligations by reporting the infection to the appropriate health authorities.

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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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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?