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 D
Explanation
The correct answer is Choice D.
Choice A rationale: Acupuncture is typically administered by a trained acupuncturist, not by the nurse. It is not commonly initiated upon arrival at the labor unit.
Choice B rationale: Biofeedback is a technique that usually requires prior training and practice; it is not typically taught for the first time at the beginning of labor.
Choice C rationale: Transcutaneous electrical nerve stimulation (TENS) can help manage back pain during labor but is not specifically used for pelvic pressure.
Choice D rationale: Using an ultrasound picture as a focal point during contractions is a common nonpharmacological pain management technique. Focal points help the client concentrate and manage pain through visualization and distraction.
Correct Answer is ["A","D"]
No explanation
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