A client is taking Rifadin (rifampin) 600 mg PO daily for pulmonary tuberculosis. The nurse should tell the client to:
- A. Take the medication with juice
- B. Expect red discoloration of the urine
- C. Take the medication before going to bed at night
- D. Take the medication only if night sweats occur
Correct Answer: B
Rationale: Rifampin causes harmless red-orange discoloration of urine, sweat, and tears, which clients should be informed about to avoid alarm. It can be taken with or without food, timing is not restricted to bedtime, and it is taken daily, not conditionally.
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A client with a history of liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.
When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?
- A. Open discussion and understanding
- B. Play-acting out feelings in different roles
- C. Storytelling
- D. Drawing pictures
Correct Answer: B
Rationale: When dealing with grief, siblings are usually most comfortable initially with open discussion. Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control. This method may be helpful, but having the child take an active part through role playing is more effective. This technique may be helpful, but being an active participant through role playing is more effective.
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be reported to the physician immediately?
- A. Potassium 7.5 mEq/L
- B. Sodium 131 mEq/L
- C. Arterial pH 7.34
- D. Hematocrit 52%
Correct Answer: A
Rationale: Hyperkalemia (7.5 mEq/L) is life-threatening, risking arrhythmias, and requires immediate reporting. Hyponatremia (B), slightly low pH (C), and elevated hematocrit (D) are less urgent in early burn care.
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