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 C

Explanation

Choice A rationale:

Heart rate 58/min. Clozapine, an atypical antipsychotic medication, can cause bradycardia (slow heart rate) as a side effect. However, the heart rate of 58/min is within the normal range for adults, so it is not a contraindication for clozapine administration.

Choice B rationale:

Fasting blood glucose 100 mg/dL. A fasting blood glucose level of 100 mg/dL is within the normal range (70-99 mg/dL) for adults. It is not a contraindication for clozapine administration.

Choice C rationale:

WBC count 2,900/mm3. Clozapine can cause agranulocytosis, a severe reduction in white blood cell (WBC) count, which can lead to increased susceptibility to infections. A WBC count of 2,900/mm3 is significantly below the normal range (4,000-11,000/mm3) and is a contraindication for clozapine administration due to the risk of severe immunosuppression.

Choice D rationale:

Hgb 14 g/dL. Hemoglobin (Hgb) level of 14 g/dL is within the normal range for adult males (13.8-17.2 g/dL) and females (12.1-15.1 g/dL). It is not a contraindication for clozapine administration.

A. "You can add the medication to a half-cup of your child's favorite juice." B. "Limit your child's potassium intake while she is taking this medication." C. "Have your child drink a small glass of water after swallowing the medication." D. "Repeat the dose if your child vomits within 1 hour after taking the medication." .

Correct Answer is C

Explanation

The correct answer is choiceC. “Have your child drink a small glass of water after swallowing the medication.”

Choice A rationale:

Adding digoxin to a half-cup of juice is not recommended because it can affect the absorption of the medication.It is best to give digoxin on an empty stomach or with a small amount of food if necessary.

Choice B rationale:

Limiting potassium intake is incorrect.In fact, maintaining adequate potassium levels is important because low potassium levels can increase the risk of digoxin toxicity.

Choice C rationale:

Having the child drink a small glass of water after taking the medication helps ensure that the medication is swallowed completely and reduces the risk of esophageal irritation.

Choice D rationale:

Repeating the dose if the child vomits within 1 hour is not recommended. If a dose is vomited, it should not be repeated to avoid the risk of overdose.The next dose should be given at the regular scheduled time.

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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?