Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. A client who received a Mantoux test 48 hr ago and has an induration.
An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.
B. A client who is scheduled for a colonoscopy and is taking sodium phosphate.
Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.
C. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L.
A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.
D. A client who is taking warfarin and has an INR of 1.8.
An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice d. A client who is taking warfarin and has an INR of 1.8.
Choice A rationale:
An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.
Choice B rationale:
Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.
Choice C rationale:
A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.
Choice D rationale:
An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.
Similar Questions
A nurse is caring for a client who has end-stage kidney disease.
The client’s adult child asks the nurse about becoming a living kidney donor for their parent.
Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?
A. Osteoarthritis.
is not a contraindication to living kidney donation. Osteoarthritis is a degenerative joint disease that does not affect the kidneys or the cardiovascular system.
B. Primary glaucoma.
primary glaucoma, is not a contraindication to living kidney donation. Primary glaucoma is a condition that causes increased pressure in the eye and can lead to vision loss if untreated. It does not affect the kidneys or the cardiovascular system. A potential donor with primary glaucoma can donate a kidney if they have normal kidney function and no other medical problems.
C. Hypertension.
hypertension. Hypertension is a contraindication to living kidney donation because it can increase the risk of kidney disease and cardiovascular complications in the donor. Hypertension can also affect the quality and survival of the donated kidney in the recipient. Therefore, a potential donor with uncontrolled or poorly controlled hypertension should not undergo nephrectomy.
D. Amputation.
is not a contraindication to living kidney donation. Amputation is the surgical removal of a limb or part of a limb due to injury, infection, or disease. It does not affect the kidneys or the cardiovascular system. A potential donor with amputation can donate a kidney if they have normal kidney function and no other medical problems. Normal ranges for blood pressure are less than 120/80 mmHg for systolic and diastolic pressure, respectively. Normal ranges for kidney function are eGFR above 60 mL/min/1.73 m2 and albuminuria below 30 mg/g.
Full Explanation
Answer and explanation.
The correct answer is choice C, hypertension. Hypertension is a contraindication to living kidney donation because it can increase the risk of kidney disease and cardiovascular complications in the donor. Hypertension can also affect the quality and survival of the donated kidney in the recipient.
Therefore, a potential donor with uncontrolled or poorly controlled hypertension should not undergo nephrectomy.
Choice A, osteoarthritis, is not a contraindication to living kidney donation.
Osteoarthritis is a degenerative joint disease that does not affect the kidneys or the cardiovascular system.
It may cause pain and stiffness in the joints, but it can be managed with medications and physical therapy. A potential donor with osteoarthritis can donate a kidney if they have normal kidney function and no other medical problems.
Choice B, primary glaucoma, is not a contraindication to living kidney donation.
Primary glaucoma is a condition that causes increased pressure in the eye and can lead to vision loss if untreated.
It does not affect the kidneys or the cardiovascular system. A potential donor with primary glaucoma can donate a kidney if they have normal kidney function and no other medical problems.
Choice D, amputation, is not a contraindication to living kidney donation.
Amputation is the surgical removal of a limb or part of a limb due to injury, infection, or disease.
It does not affect the kidneys or the cardiovascular system. A potential donor with amputation can donate a kidney if they have normal kidney function and no other medical problems.
Normal ranges for blood pressure are less than 120/80 mmHg for systolic and diastolic pressure, respectively.
Normal ranges for kidney function are eGFR above 60 mL/min/1.73 m2 and albuminuria below 30 mg/g.
A nurse is assessing a client immediately following a cardiac catheterization.
The nurse should notify the provider for which of the following findings?
A. Heart rate 90/min.
because heart rate 90/min is within the normal range for adults and does not indicate a complication.
B. Hematoma over the insertion site.
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization. The nurse should notify the provider immediately if a hematoma is observed.
C. Bounding pulses in the affected extremity.
because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
D. Report of discomfort at the insertion site continue.
because report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
Full Explanation
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because heart rate 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed, but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
A nurse is planning to teach a client about taking prednisone.
Which of the following instructions should the nurse include
A. Increase dietary calcium.
dietary calcium. Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.
B. Monitor for weight loss.
prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.
C. Take on an empty stomach.
wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomach.
D. Schedule dosage at bedtime.
wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.
Full Explanation
The correct answer is A. Increase dietary calcium. Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.
Choice B is wrong because prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.
Choice C is wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomach.
Choice D is wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.