Nokea
A nurse in a clinic receives a telephone call from a client who has tuberculosis and was prescribed rifampin 3 days ago. The client reports, 'My saliva and tears are red. What should I do?' Which of the following responses by the nurse is appropriate?
- A. This is an expected adverse effect of the medication.'
- B. Stop taking the medication. You are having an allergic reaction.'
- C. This condition will only last a couple of days.'
- D. Taking the medication with red meat will cause this adverse effect.'
Correct Answer: A
Rationale: The correct response is A: "This is an expected adverse effect of the medication." Red discoloration of bodily fluids is a known side effect of rifampin. The medication can cause harmless discoloration of saliva, tears, sweat, and urine. It does not indicate an allergic reaction or a serious issue that requires stopping the medication. Choice B is incorrect as stopping the medication abruptly is not necessary. Choice C is incorrect as the duration of this side effect varies. Choice D is incorrect as the discoloration is not related to the consumption of red meat.
You may also like to solve these questions
A nurse is reinforcing teaching with a client who has COPD and has been taking long-term high doses of prednisone. Which of the following instructions should the nurse include in the teaching?
- A. Limit potassium-containing foods in your diet.'
- B. Withhold prednisone for 48 hours prior to receiving contrast dye.'
- C. Measure your blood glucose levels periodically.'
- D. Take prednisone on an empty stomach.'
Correct Answer: C
Rationale: The correct answer is C: Measure your blood glucose levels periodically. Clients taking long-term high doses of prednisone are at risk for developing steroid-induced diabetes due to the drug's effect on blood glucose levels. Monitoring blood glucose levels will help detect any abnormalities early, allowing for timely intervention.
A: Limiting potassium-containing foods is not directly related to prednisone use in COPD.
B: Withholding prednisone for 48 hours prior to receiving contrast dye can lead to adrenal insufficiency in clients on long-term prednisone therapy.
D: Taking prednisone on an empty stomach is not a specific instruction related to managing COPD or prednisone therapy.
Nurses Notes
Plan of Care
Provider Prescriptions
Vital Signs
Admissions Assessment
6 months ago:
The client was diagnosed with epilepsy during childhood. The client reports not having seizures for 2 years. The client has weaned off all seizure medications. The client was informed to return to the office for a follow-up in 6 months and to call the office if seizure activity resumes
Today:
The client reports having a seizure this morning. Provider aware and new prescription obtained.
Click to highlight the findings that require immediate follow-up as contraindications to the prescribed prescription (phenytoin).
- A. Client is a vegetarian and takes a multivitamin daily
- B. Client reports having three to four alcoholic beverages a couple times per week
- C. Last menstrual period was 3 months ago
- D. Client takes diazepam as needed for anxiety
Correct Answer: A,B,C,D
Rationale: [1,1,1,1]
The correct answer is A, B, C, D.
A: Vegetarian diet may lack sufficient Vitamin K, which interacts with phenytoin.
B: Alcohol increases phenytoin levels, leading to toxicity.
C: Missed periods could indicate pregnancy, a contraindication for phenytoin.
D: Diazepam increases sedation when combined with phenytoin.
Incorrect choices:
E, F, G: These choices do not directly interact with phenytoin or have contraindications.
Nurses' Notes
Vital Signs
Laboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
A nurse is assisting in the care of a female client.
Complete the following sentence by using the lists of options: The nurse should first address the client ___ followed by the client's ___.
- A. blood pressure
- B. Hgb level
- C. temperature
- D. potassium level
- E. abdominal findings
- F. Hct level
Correct Answer: A,D
Rationale: Sure, here is the detailed explanation for the correct answer :
1. **Blood pressure (A)**: The nurse should first address the client's blood pressure as it is a vital sign that provides immediate information about the client's cardiovascular health and overall perfusion status.
2. **Potassium level (D)**: Following the assessment of blood pressure, addressing the client's potassium level is important as potassium imbalances can have critical implications on cardiac function and require prompt intervention.
**Summary**:
- **Incorrect Choices**:
- B: Hgb level and F: Hct level are related to blood components and not typically the first priority in a general assessment.
- C: Temperature is important but may not be the immediate priority compared to blood pressure and potassium level.
- E: Abdominal findings are important but may not be the initial focus in this context.
- **Correct Choices**:
- A: Blood pressure and D: Potassium level are crucial in
A nurse is collecting data from a client who has gout and is taking allopurinol. Which of the following adverse effects should the nurse identify as the priority to report to the provider?
- A. Rash
- B. Diarrhea
- C. Nausea
- D. Metallic taste in mouth
Correct Answer: A
Rationale: The correct answer is A: Rash. A rash could indicate a severe allergic reaction or Stevens-Johnson syndrome, a potentially life-threatening skin disorder associated with allopurinol. This adverse effect requires immediate medical attention to prevent serious complications.
B: Diarrhea, C: Nausea, and D: Metallic taste in mouth are common side effects of allopurinol but not typically considered urgent or life-threatening. Reporting them to the provider is important, but they do not require immediate attention like a rash.
A nurse is administering heparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Aspirate before injecting the medication
- B. Use a 25-gauge, 1/2-inch needle to administer the medication
- C. Administer the medications within 2 cm (1 in) of the umbilicus
- D. Massage the site after injecting the medication.
Correct Answer: B
Rationale: The correct answer is B: Use a 25-gauge, 1/2-inch needle to administer the medication. This gauge and length are appropriate for subcutaneous injections to avoid reaching muscle tissue. Using a smaller needle minimizes tissue trauma, discomfort, and the risk of bleeding. Aspiration before injecting is unnecessary for subcutaneous injections as there are no large blood vessels in the subcutaneous tissue, making it safer to skip this step. Administering the medication within 2 cm of the umbilicus is not recommended as it could lead to irritation or infection at the site. Massaging the site after injecting the medication is contraindicated as it can cause bruising or discomfort.