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A client has a new prescription for rifampin. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Expect red-orange discoloration of body fluids.
- C. Monitor for signs of hyperglycemia.
- D. Avoid consuming dairy products.
Correct Answer: B
Rationale: The correct answer is to inform the client to expect red-orange discoloration of body fluids when taking rifampin. This side effect is harmless but can be surprising to patients. It is important for the nurse to educate the client about this expected change to prevent unnecessary concern or alarm. Monitoring for hyperglycemia is not directly related to rifampin, and taking the medication with food or avoiding dairy products are not specific instructions for this medication.
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A client with a diagnosis of acute myocardial infarction (MI) is receiving thrombolytic therapy. The nurse monitors the client for which potential complication associated with this therapy?
- A. Hypertension
- B. Bleeding
- C. Hyperkalemia
- D. Hypoglycemia
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of hypertension is prescribed atenolol (Tenormin). The nurse should monitor the client for which common side effect of this medication?
- A. Tachycardia
- B. Dry mouth
- C. Hypotension
- D. Increased appetite
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with a history of coronary artery disease (CAD) is scheduled for a stress test. What instruction should the nurse provide to the client before the test?
- A. Continue taking your usual dose of beta-blockers
- B. Refrain from eating or drinking anything for 4 hours before the test
- C. Wear loose, comfortable clothing and walking shoes
- D. Avoid any physical activity for 24 hours before the test
Correct Answer: C
Rationale: The correct instruction for the client before a stress test is to wear loose, comfortable clothing, and walking shoes. This is crucial as the stress test involves physical exercise, and the client should be prepared for the activity involved. Beta-blockers may need to be adjusted or held before the test as per healthcare provider's instructions. Fasting before the test is not typically required, and avoiding physical activity for 24 hours beforehand is not necessary and may interfere with the accuracy of the test results.
A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?
- A. Administer morphine
- B. Obtain an electrocardiogram (ECG)
- C. Apply oxygen via nasal cannula
- D. Administer sublingual nitroglycerin
Correct Answer: B
Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action.
The nurse is caring for a client with coronary artery disease (CAD) who reports chest pain. The nurse administers nitroglycerin as prescribed. What is the next priority action?
- A. Obtain a 12-lead ECG
- B. Monitor the client's blood pressure
- C. Notify the healthcare provider
- D. Administer a second dose of nitroglycerin
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.