Nokea
A client with pulmonary tuberculosis has been taking rifampin for 3 weeks. The client reports orange urine. What should be the nurse's next action?
- A. Notify the client's health care provider.
- B. Inform the client that this is not harmful.
- C. Assess the client for other signs of nephrotoxicity.
- D. Monitor the client's most recent creatinine level.
Correct Answer: B
Rationale: The correct action for the nurse to take when a client reports orange urine after taking rifampin is to inform the client that this change is not harmful. Rifampin is known to cause orange discoloration of urine, which is a harmless side effect. There is no need to notify the health care provider as this is an expected outcome. Monitoring creatinine levels or assessing for nephrotoxicity is unnecessary in this situation, as rifampin does not typically cause kidney damage.
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In the immediate postoperative period, a client is prescribed morphine via a patient-controlled analgesia (PCA) pump. Which finding should the PN consider the highest priority in this client?
- A. Monitoring the expiration date of the PCA morphine
- B. Assessing the rate and depth of the client's respirations
- C. Reviewing the type of anesthesia used during the surgery
- D. Observing the client's signs of disorientation
Correct Answer: B
Rationale: The highest priority for the PN is to assess the rate and depth of the client's respirations when a client is receiving morphine via a PCA pump. Respiratory depression is a life-threatening side effect of intravenous morphine administration. If the client's respiratory rate falls below 10 breaths/min, the PCA pump should be stopped, and the healthcare provider must be notified immediately to prevent further complications.
A client with diabetes mellitus type 1 is prescribed insulin glargine. When should the nurse instruct the client to administer this medication?
- A. Before meals
- B. After meals
- C. At bedtime
- D. In the morning
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The practical nurse administered carbidopa-levodopa to a client diagnosed with Parkinson's disease. Which outcome by the client would indicate a therapeutic response?
- A. Decreased blood pressure
- B. Lessening of tremors
- C. Increased salivation
- D. Increased attention span
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with epilepsy is prescribed lamotrigine. The nurse should monitor for which potential side effect?
- A. Drowsiness
- B. Nausea and vomiting
- C. Skin rash
- D. Dizziness
Correct Answer: C
Rationale: When a client is prescribed lamotrigine, the nurse should closely monitor for the potential side effect of skin rash. Lamotrigine is known to cause skin rashes, which can be mild or severe, indicating a serious adverse reaction like Stevens-Johnson syndrome. Monitoring for skin rash is crucial to detect any signs of severe allergic reactions early and prevent further complications.
Which action should be taken to assess for analgesic tolerance in a client who is unable to communicate?
- A. Review the client's laboratory values for changes in peak and trough levels of the analgesic
- B. Prolong the interval between analgesic medication doses and monitor the client's vital signs
- C. Observe the client for the presence of pain behaviors before the next analgesic dose is due
- D. Ask family members to report behaviors suggesting that the client's pain has returned
Correct Answer: C
Rationale: In clients who are unable to communicate, observing for pain behaviors is crucial in assessing analgesic tolerance. Changes in pain behaviors can indicate if the current analgesic regimen is effective or if tolerance has developed. Therefore, closely observing the client for pain behaviors before the next analgesic dose helps healthcare providers evaluate the client's response to pain management.