A nurse is performing a neurological examination on a client as part of a complete physical assessment.
The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

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.

Answer is: c. Protect the IV bag from exposure to light.

Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.

Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.

Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.

Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.