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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Choosing an agency to provide home physical therapy is important, but it is not the priority in this situation. The client's safety and immediate needs should be addressed first.

Choice B rationale:

Obtaining an alert system to get help in case of a fall is the priority for an older adult living alone with left-sided weakness following a stroke. Falls can result in serious injuries, so having an alert system ensures the client can call for assistance promptly, enhancing their safety and well-being.

Choice C rationale:

Providing information about available transportation resources is important for the client's long-term independence and quality of life. However, immediate safety concerns, such as the risk of falls, should be addressed first.

Choice D rationale:

Reviewing information about support groups for individuals who have had a stroke is essential for the client's emotional well-being and social support. However, immediate safety measures, such as fall prevention, take precedence in this scenario.

A. Manage conflict within the group. B. Encourage the use of problem-solving skills. C. Maintain the group's focus on identified issues. D. Establish a rapport with group members.

Correct Answer is D

Explanation

Choice A rationale:

Managing conflict within the group is an important skill, but it is more appropriate for the working phase of group therapy. During the orientation phase, the focus is on establishing trust, setting group norms, and creating a safe environment. Conflict resolution skills become more relevant as the group progresses.

Choice B rationale:

Encouraging the use of problem-solving skills is essential in group therapy, but it is a skill that is developed during the working phase. During the orientation phase, the nurse focuses on building rapport, creating a comfortable atmosphere, and explaining the purpose and goals of the group.

Choice C rationale:

Maintaining the group's focus on identified issues is a crucial aspect of the orientation phase. The nurse should guide the discussion to ensure that participants understand the purpose of the group and stay on topic. This helps in establishing clear goals and expectations for the group sessions.

Choice D rationale:

Establishing a rapport with group members is a primary goal of the orientation phase. Building trust and a therapeutic relationship with the adolescents creates a supportive environment where they feel comfortable sharing their experiences and emotions. A strong rapport enhances the effectiveness of the support group.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.Which of the following information is the priority for the nurse to discuss?

Correct Answer is B

Explanation

A nurse is planning to conduct a support group for adolescents who have cancer.Which of the following actions should the nurse include during the orientation phase?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a fever due to an infection.Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?

A nurse is reviewing the medication administration record of a client.Which of the following prescriptions should the nurse clarify?

A nurse is providing teaching to a client who has a new colostomy.Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg.Which of the following actions should the nurse take to protect the client's confidentiality?

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate?

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

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?