Nokea
A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?
- A. Reddish-orange discoloration of body fluids
- B. Bloody or blood-tinged urine
- C. Blurring of vision
- D. Weight gain of more than 2 pounds in a week
Correct Answer: A
Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.
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A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?
- A. Administer oxygen
- B. Perform chest physiotherapy
- C. Elevate the head of the bed
- D. Obtain a sputum specimen
Correct Answer: A
Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.
At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
- A. Encourage the woman to explore her fears about breast cancer.
- B. Ask the woman if she also performs monthly breast self-exams.
- C. Commend the woman for adhering to the recommended cancer detection guidelines.
- D. Advise the woman that mammograms are only needed every two years at her age.
Correct Answer: B
Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.
The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?
- A. Client reports itching under the cast
- B. Client reports pain at the cast site
- C. Client reports swelling of the fingers
- D. Client reports warmth over the casted area
Correct Answer: C
Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.
A male client with hypertension tells the nurse that he is going to take ginseng to increase his stamina. What information should the nurse provide this client?
- A. Ginseng can decrease the effectiveness of your blood pressure medication
- B. You will need to stop taking ginseng while on blood pressure medication
- C. It is important to monitor your blood pressure regularly while taking ginseng
- D. Ginseng can increase your blood pressure
Correct Answer: D
Rationale: The correct answer is D: "Ginseng can increase blood pressure, which is a concern for clients with hypertension." Choice A is incorrect because ginseng does not typically decrease the effectiveness of blood pressure medication. Choice B is incorrect as stopping ginseng while on blood pressure medication may not be necessary. Choice C is not the most direct concern related to ginseng use in a hypertensive client, making it less relevant than the correct answer.
When obtaining a urine specimen from a female infant, which intervention should the nurse implement?
- A. Place the wet diaper in a biohazard specimen bag
- B. Obtain the urine sample using a straight size 4 French catheter
- C. Collect the urinary stream in mid-air when the infant cries
- D. Secure the pediatric urine collector bag to the perineum
Correct Answer: D
Rationale: When obtaining a urine specimen from a female infant, securing the pediatric urine collector bag to the perineum is the most appropriate intervention. This method allows for non-invasive collection of urine without causing discomfort or distress to the infant. Placing the wet diaper in a biohazard specimen bag (Choice A) is incorrect as it does not involve collecting a fresh urine sample. Using a catheter (Choice B) is invasive and not typically necessary for routine urine specimen collection from infants. Collecting the urinary stream in mid-air when the infant cries (Choice C) is not a reliable or hygienic method of obtaining a urine specimen.