A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.

A client who received a Mantoux test 48 hr ago and has an induration

A client who is taking bumetanide and has a potassium level of 3.6 mEq/L

A client who is scheduled for a colonoscopy and is taking sodium phosphate

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

Answer and Explanation

The Correct Answer is D

A.    Induration after a Mantoux test is a common response and does not necessarily require follow-up care.
B.    A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L).
C.    Sodium phosphate is commonly used for bowel preparation before procedures like colonoscopy.
D.    Correct. An INR of 1.8 for a client on warfarin is below the therapeutic range (usually 2.0- 3.0 for most indications), indicating that the client's blood may not be adequately anticoagulated. This requires follow-up to adjust the warfarin dose.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Correct. A filter needle should be used to withdraw medication from an ampule to prevent drawing up any glass fragments into the syringe.
B. Using the same needle to draw up and inject the client is not recommended to prevent contamination.
C. Breaking the neck of the ampule toward the body is not a safe practice, as it can cause injury.
D. Ampules should be disposed of properly in a sharps container, not a regular trash can.

A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency

Correct Answer is C

Explanation

A. Bleeding gums are common during pregnancy due to hormonal changes that make gums more sensitive and prone to bleeding. This is not typically a sign of a serious condition and can usually be managed with good oral hygiene.

B. Faintness or lightheadedness upon rising is common in pregnancy due to blood pressure changes. This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.

C. Swelling of the face during pregnancy can be an early sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage. This is a concerning symptom that requires immediate evaluation by a healthcare provider.

D. Urinary frequency is a common and usually benign symptom during pregnancy, especially in the first and third trimesters due to hormonal changes and pressure on the bladder. It does not typically require urgent reporting unless accompanied by other symptoms such as pain or burning during urination, which could indicate a urinary tract infection.

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A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.

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Naxlex Comprehensive Predictor Exams

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