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 taking warfarin and has an INR of 1.8.

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.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is A

Explanation

The correct answer is choice a. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia due to reduced energy supply.

Choice B rationale:

Fetal anemia typically causes fetal tachycardia rather than bradycardia, as the fetus compensates for the lack of oxygen-carrying capacity by increasing the heart rate.

Choice C rationale:

Chorioamnionitis, an infection of the fetal membranes, usually causes fetal tachycardia due to the inflammatory response and fever.

Choice D rationale:

Maternal fever is more likely to cause fetal tachycardia rather than bradycardia, as the increased maternal temperature can lead to an increased fetal heart rate.

A. Administer a bronchodilator after meals. B. Ambulate the client before each meal. C. Limit fluid intake with meals. D. Offer the client three large meals each day.

Correct Answer is C

Explanation

The correct answer is choice c. Limit fluid intake with meals.

Choice A rationale:

Administering a bronchodilator after meals is not ideal because bronchodilators are typically given before meals to help open the airways and make breathing easier during eating.

Choice B rationale:

Ambulating the client before each meal might cause fatigue, making it harder for the client to eat and potentially decreasing their overall intake.

Choice C rationale:

Limiting fluid intake with meals can help prevent the client from feeling too full, which can make it easier for them to consume more solid food. This is particularly important for clients with COPD who may already have a reduced appetite and difficulty eating large amounts at once.

Choice D rationale:

Offering three large meals each day is not recommended for clients with COPD. Smaller, more frequent meals are generally better tolerated and can help prevent the feeling of fullness that can make breathing more difficult.

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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?