Nokea
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who received a Mantoux test 48hr ago and has an induration
- B. A client who is schedule for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8(low INR clotting)
- D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care because it indicates insufficient anticoagulation, putting the client at risk for clot formation. An INR of 1.8 is below the therapeutic range (usually 2-3 for most indications) for warfarin therapy. This can lead to inadequate prevention of blood clots, increasing the risk of thromboembolic events. Follow-up care may involve adjusting the warfarin dosage to achieve the target INR range.
Choice A is incorrect because an induration after a Mantoux test is an expected finding and does not necessarily require follow-up care. Choice B is incorrect as taking sodium phosphate before a colonoscopy is a standard preparation and does not indicate a need for immediate follow-up care. Choice D is incorrect as a potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L
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Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.
For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.
Complete the sentence using the lists of options.The child is at highest risk for developing------------evidenced by the child's-----------
- A. compartment syndrome
- B. circulatory impairment
- C. abrasion and bruising
- D. paresthesia
- E. nerve damage
Correct Answer: B,D
Rationale: Circulatory impairment is evidenced by paresthesia (tingling), indicating compromised blood flow.
Select the findings that indicate the interventions have been effective.
- A. Client rates pain with contractions as a 3 on a scale of 0 to 10
- B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
- C. Accelerations present, no decelerations noted
- D. Heart rate 88/min
- E. Blood pressure 122/80 mm Hg
- F. Temperature 38° C(100.4° F)
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.
Select the findings that indicate the client is experiencing adverse effects of the medication.
- A. Client states, 'I am feeling much better'
- B. Difficulty sleeping
- C. Client continues to deny any suicidal ideation
- D. BP 169/91 mm HG
- E. Respiratory rate 18/min
Correct Answer: B,D
Rationale: Hypertension and difficulty sleeping are potential side effects of certain medications.