A nurse is caring for a client in an acute care setting.

Exhibits

The client is at risk for ________ as evidences by __________.

Complete the following sentence by using the list of options. Pick 2 choices.

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.

In the context of an emergency response plan following an external disaster and the need to create bed space for potential admissions, the nurse should consider early discharge for clients who are stable and whose discharge will not compromise their safety or health. Based on the given options, the most appropriate candidate for early discharge would be:

B) A client who is 1 day postoperative following a vertebroplasty.

Clients who are one day postoperative after a vertebroplasty are typically recovering from a relatively minor procedure and may be stable for discharge if their condition remains uncomplicated.

The other options:

A) A client receiving heparin for deep-vein thrombosis may require ongoing monitoring and treatment, and early discharge might not be appropriate.

C) A client with cancer and a sealed implant for radiation therapy likely has specific treatment needs and should not be discharged early.

D) A client with COPD and a respiratory rate of 44/min likely has respiratory distress and should not be discharged early. Their condition requires close monitoring and intervention.