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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Correct Answer is ["A","D","E","F","G"]

Explanation

Based on the information provided, the nurse should consider the following client findings for further evaluation:

A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.

D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.

E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.

F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.

G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.

The following client findings do not necessarily indicate the need for further evaluation in this context:

B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.

C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.

A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.

A. Suggest rinsing his mouth with an alcohol-based mouthwash. B. Provide humidification of the room air. C. Offer the client saltine crackers between meals. D. Instruct the client on the use of esophageal speech.

Correct Answer is B

Explanation

A. Alcohol-based mouthwashes can exacerbate dry mouth (xerostomia) and should be avoided.
B. Correct. Providing humidification of the room air can help alleviate the symptoms of xerostomia.
C. Saltine crackers may not significantly help with xerostomia.
D. Esophageal speech is unrelated to xerostomia.

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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

A nurse is caring for a client who presents to the emergency department. Exhibits A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation? (Select All that Apply.)

Correct Answer is ["A","D","E","F","G"]

Explanation

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Correct Answer is B

Explanation

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