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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Hypoglycemia refers to low blood sugar levels. This condition can occur in newborns, especially those born to mothers with diabetes, preterm babies, babies who are small for gestational age, or those who have experienced a difficult delivery. However, the provided information does not indicate any signs of hypoglycemia such as jitteriness, poor feeding, or lethargy.
Choice B rationale: Bronchopulmonary dysplasia (BPD) is a chronic lung disease that affects newborns and infants. It’s more common in premature infants who have received oxygen therapy or mechanical ventilation. The newborn’s information does not suggest any risk factors for BPD.
Choice C rationale: Transient tachypnea of the newborn (TTN) is a respiratory problem that can be seen shortly after delivery in babies who have no other health issues. It’s caused by fluid in the lungs. The newborn’s increased respiratory rate and grunting are signs of TTN. This condition is more common in babies delivered via cesarean birth, as in this case.
Choice D rationale: Tachycardia refers to a heart rate that’s too fast. While the newborn’s heart rate is on the higher side of normal (normal range: 120-160 beats per minute), it’s not high enough to be considered tachycardia. Therefore, based on the provided information, the newborn is at risk for developing Transient tachypnea of the newborn (Choice C). The other conditions mentioned do not align with the symptoms and risk factors presented in the scenario.
Correct Answer is A
Explanation
Choice A rationale:
Crackles in the lungs are a common manifestation of heart failure. Heart failure can cause fluid accumulation in the lungs, leading to crackles upon auscultation. This finding is due to pulmonary congestion and is indicative of heart failure exacerbation.
Choice B rationale:
Decreased thirst is not a typical manifestation of heart failure. In fact, patients with heart failure often experience increased thirst due to fluid shifts and increased blood volume, leading to increased urine output and dehydration.
Choice C rationale:
Poor skin turgor is not a specific manifestation of heart failure. Skin turgor is commonly assessed to determine hydration status, but it is not directly related to heart failure.
Choice D rationale:
Tachycardia (rapid heart rate) is a common manifestation of heart failure. The heart beats faster to compensate for its decreased pumping efficiency. Tachycardia helps maintain cardiac output, but it is not a primary cause of heart failure; instead, it is a physiological response to the condition.
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