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 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.

A client who is taking warfarin and has an INR of 1.8.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

A Mantoux test with an induration after 48 hours can be a normal reaction, especially if the induration is within the expected size range for a positive result, depending on the individual’s risk factors and history. It does not necessarily require follow-up care unless the induration is significantly large or there are other concerning symptoms.

Choice B rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not typically require follow-up care for the sodium phosphate intake itself. Sodium phosphate is commonly used as a bowel prep medication to clear the intestines prior to the procedure.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L), so a client taking bumetanide with this potassium level would not typically require follow-up care for the potassium level alone.

Choice D rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care because the therapeutic range for warfarin is typically between 2.0 and 3.0 for most indications. An INR of 1.8 may indicate that the blood is not “thin” enough, increasing the risk of thrombotic events, and the warfarin dose may need adjustment.

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Correct Answer is A

Explanation

Furosemide is a loop diuretic that is used to treat fluid volume excess by increasing the excretion of water and electrolytes through the kidneys. Weight loss is an indication that the medication has been effective in reducing the excess fluid in the body.
Choice B is wrong because decreased inflammation is not a direct effect of furosemide.
Inflammation is a response to tissue injury or infection, and furosemide does not have any anti-inflammatory properties.
Choice C is wrong because increased blood pressure is not an indication of furosemide effectiveness.
Furosemide lowers blood pressure by reducing the preload and afterload on the heart.
Increased blood pressure may indicate that the dose of furosemide is insufficient or that there are other factors contributing to hypertension.
Choice D is wrong because decreased pain is not an expected outcome of furosemide therapy.
Furosemide does not have any analgesic effects, and pain may be caused by various conditions that are not related to fluid volume excess.
Normal ranges for weight, blood pressure, and pain vary depending on the individual patient’s baseline and goals.
However, some general guidelines are:
• Weight: A weight loss of 0.5 to 1 kg per day is considered safe and effective for patients with fluid volume excess.
• Blood pressure: The target blood pressure for most patients with heart failure is less than 130/80 mmHg.
• Pain: The pain level should be assessed using a valid and reliable scale, such as the numeric rating scale or the visual analog scale, and treated according to the patient’s preference and tolerance.

A. Hypertension. B. Hypothyroidism. C. Obesity. D. Herpes zoster.

Correct Answer is D

Explanation

Herpes zoster is a contraindication for receiving acupuncture treatment because it is an infectious skin disorder that can be transmitted by needles or contact with the affected area. Acupuncture should not be performed on areas of skin that are inflamed, ulcerated, or have sensory deficits.
Choice A is wrong because hypertension is not a contraindication for acupuncture. However, some caution is advised when needling points that may lower blood pressure, such as LI 4, LI 11, ST 36, and SP 6.
Choice B is wrong because hypothyroidism is not a contraindication for acupuncture. In fact, some studies suggest that acupuncture may have beneficial effects on thyroid function and symptoms of hypothyroidism.
Choice C is wrong because obesity is not a contraindication for acupuncture.
Acupuncture may help with weight loss by regulating appetite, metabolism, and hormones.
Some of the absolute contraindications for acupuncture include pregnancy (especially certain points that may induce labor or abortion), medical and surgical emergencies, malignant tumors, bleeding disorders, and the use of a demand pacemaker. Some of the relative contraindications include drug or alcohol intoxication, lack of consent, immune deficiency, abnormal heart valves, and fear of needles.

Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressure respectively.
Normal ranges for thyroid-stimulating hormone (TSH) are 0.4 to 4.0 mIU/L. Normal ranges for body mass index (BMI) are 18.5 to 24.9 kg/m2.

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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.