Nokea
A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply.
- A. Mailing eye examinations every 6 months.
- B. Maintaining follow-up monitoring of liver enzymes.
- C. Decreasing protein intake in the diet.
- D. Avoiding alcohol intake.
- E. The urine may have an orange color.
Correct Answer: B,D,E
Rationale: Rifampin requires liver enzyme monitoring (B) and alcohol avoidance (D) due to hepatotoxicity risk. Orange urine (E) is a harmless side effect. Eye exams and reduced protein intake are not indicated.
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The nurse is caring for a client with a new colostomy and notices the client is reluctant to participate in self-care. Which intervention should the nurse implement first?
- A. Teach the client's family to perform colostomy care.
- B. Refer the client to a support group.
- C. Assess the client's barriers to self-care.
- D. Provide written instructions for colostomy care.
Correct Answer: C
Rationale: Assessing the client's barriers to self-care is the first step to understand and address their reluctance, enabling tailored interventions. Teaching family, referring to a support group, or providing instructions are secondary after identifying the underlying issues. CN: Psychosocial adaptation; CL: Synthesize
A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, 'Why does she have this tube inserted in her hip?' Which of the following responses would be best?
- A. The tube helps us to detect a wound infection early on.'
- B. This way we won't have to irrigate the wound.'
- C. Fluid won't be allowed to accumulate at the site.'
- D. We have a way to administer antibiotics into the wound.'
Correct Answer: C
Rationale: The drainage tube prevents fluid accumulation, reducing infection risk and promoting healing.
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when:
- A. There is no odor from the stoma.
- B. The client is adequately hydrated.
- C. There is no skin irritation around the stoma.
- D. The client only changes the ostomy pouch once a day.
Correct Answer: C
Rationale: Correct application of a skin barrier is indicated by no skin irritation around the stoma, as the barrier protects the peristomal skin. Odor, hydration, and pouch change frequency are not direct indicators of proper barrier use. CN: Physiological adaptation; CL: Evaluate
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action?
- A. Activate the rapid response team.
- B. Assess the client's orientation and vital signs.
- C. Administer a bolus of lidocaine.
- D. Notify the physician.
Correct Answer: B
Rationale: PVCs every other beat (bigeminy) may indicate serious irritability. Assessing orientation and vital signs first determines the client's stability, guiding further actions.
Which of the following has been identified as a potential risk factor for the development of colon cancer?
- A. Chronic constipation.
- B. Long-term use of laxatives.
- C. History of smoking.
- D. History of inflammatory bowel disease.
Correct Answer: D
Rationale: A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet. CN: Reduction of risk potential; CL: Analyze