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?
Explanation & Rationale
A. A client who received a Mantoux test 48 hr ago and has an induration: The presence of induration is expected in a positive Mantoux test and does not necessarily require follow-up unless the induration is large, indicating possible tuberculosis exposure. B. A client who is taking warfarin and has started to breastfeed: This situation requires follow-up care. While warfarin can be used during breastfeeding, careful monitoring is needed due to potential effects on the infant and the necessity of maintaining therapeutic INR levels. C. A client who is taking bumetanide and reports an increase in urinary frequency: This is a normal side effect of bumetanide, a diuretic, and does not require follow-up unless there are additional concerning symptoms. D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: This is a common preparation for a colonoscopy, and while electrolyte balance should be monitored, it does not inherently indicate a need for follow-up care unless there are specific issues reported.