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.
B.
A client who is scheduled for a colonoscopy and is taking sodium phosphate.
C.
A client who is taking bumetanide and has a potassium level of 3.6 mEq/L.
D.
A client who is taking warfarin and has an INR of 1.8.
The Correct Answer and Explanation is:
The correct answer is D. A client who is taking warfarin and has an INR of 1.8.
Explanation:
Warfarin is an anticoagulant medication used to prevent blood clots, and its effectiveness is monitored by measuring the International Normalized Ratio (INR). The INR provides a standardized way to evaluate the blood’s ability to clot, and it is a critical measure for clients on warfarin to ensure that their blood is thin enough to prevent clotting but not too thin to cause bleeding.
For most clients on warfarin for conditions like atrial fibrillation or deep vein thrombosis, the therapeutic INR range is typically between 2.0 to 3.0. In some cases, such as clients with mechanical heart valves, a higher target INR may be required (e.g., 2.5 to 3.5). An INR of 1.8 is below the therapeutic range, indicating that the client’s blood is not anticoagulated enough, putting them at increased risk for clot formation. This subtherapeutic INR requires follow-up because the warfarin dosage may need adjustment to reach the appropriate therapeutic range.
A: A client who received a Mantoux test 48 hours ago and has an induration.
- The Mantoux test is used to screen for tuberculosis (TB). An induration at the test site can be a normal finding, depending on the size and risk factors of the client. However, induration alone does not always require immediate follow-up without considering the context.
B: A client who is scheduled for a colonoscopy and is taking sodium phosphate.
- Sodium phosphate is often used as a bowel preparation for colonoscopy. As long as the client is properly hydrated and follows pre-procedure guidelines, this does not typically require follow-up.
C: A client who is taking bumetanide and has a potassium level of 3.6 mEq/L.
- Bumetanide is a loop diuretic that can cause hypokalemia (low potassium levels). However, a potassium level of 3.6 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not necessitate follow-up.
Thus, D requires follow-up to ensure that the INR is within the therapeutic range for adequate anticoagulation.