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 ["A","B","D","F"]
Explanation
The correct answer is choice A, B, D, and F.
Choice A rationale:
The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.
Choice B rationale:
The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.
Choice C rationale:
The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.
Choice D rationale:
The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.
Choice E rationale:
The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.
Choice F rationale:
The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.
Choice G rationale:
The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.
Correct Answer is A
Explanation
Choice A rationale:
Lavender oil is commonly used in aromatherapy and is known for its calming effects. However, it can trigger respiratory issues in individuals with asthma. Asthma is a chronic condition characterized by airway inflammation and bronchoconstriction, which can be exacerbated by inhaling certain substances, including strong odors and essential oils. Lavender oil, when inhaled, can potentially irritate the airways and worsen asthma symptoms. Therefore, a history of asthma is a contraindication for using lavender oil.
Choice B rationale:
Furosemide is a diuretic commonly used to treat fluid retention (edema) and hypertension. It works by increasing urine production and removing excess fluid from the body. Furosemide does not interact with lavender oil directly, and there is no known contraindication between these two substances.
Choice C rationale:
Alcohol use disorder is a condition characterized by an inability to control or stop alcohol consumption despite negative consequences. While alcohol abuse can have various health implications, it does not specifically interact with lavender oil in a way that constitutes a contraindication.
Choice D rationale:
Vitamin C is a water-soluble vitamin that plays a crucial role in various bodily functions, including immune system support and collagen synthesis. There is no evidence to suggest that taking vitamin C daily contraindicates the use of lavender oil. These two substances do not interact in a way that poses a risk to the individual.
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