Nokea
An adult with tuberculosis has started taking rifampin (Rimactane). Which side effect is the client most likely to experience when taking this drug?
- A. Reddish-orange color of urine, sputum, and saliva
- B. Erythema and urticaria
- C. Tinnitus and deafness
- D. Peripheral neuritis
Correct Answer: A
Rationale: Rifampin commonly causes a harmless reddish-orange discoloration of body fluids.
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Because of this client's impaired speech, which nursing action facilitates communication?
- A. Discourage the client's attempts at communication.
- B. Inform the client to speak slowly when talking.
- C. Listen attentively to the client's vocalizations.
- D. Provide the client with paper and pencil.
Correct Answer: D
Rationale: Providing paper and pencil allows the client with impaired speech post-laryngectomy to communicate effectively through writing.
When the client asks why the physician chose this particular drug to treat the pneumonia, which response by the nurse is best?
- A. The sensitivity report showed the organism is often killed by penicillin.
- B. Most viral infections respond well when treated with penicillin drugs.
- C. Penicillin is one of the safest yet most effective antibiotics.
- D. All antibiotics are similar; the choice of drug is not that important.
Correct Answer: A
Rationale: Penicillin is chosen based on the sensitivity report, indicating that the pneumococcal bacteria are susceptible to it.
The client diagnosed with oat cell carcinoma of the lung tells the nurse, 'I am so tired of all this. I might as well just end it all.' Which statement should be the nurse's first response?
- A. Say, 'This must be hard for you. Would you like to talk?'
- B. Tell the HCP of the client's statement.
- C. Refer the client to a social worker or spiritual advisor.
- D. Find out if the client has a plan to carry out suicide.
Correct Answer: A
Rationale: Acknowledging feelings and offering to talk (A) opens communication for suicidal ideation. Notifying HCP (B), referring (C), and assessing plans (D) follow.
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first?
- A. Administer oxygen 10 L via nasal cannula.
- B. Place the client in high Fowler's position.
- C. Obtain a STAT pulse oximeter reading.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: High Fowler’s position (B) improves breathing in suspected PE, a priority. Oxygen (A), SpO2 (C), and lung sounds (D) follow to support and assess.
The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply.
- A. The client will be able to speak again after the surgery area has healed.
- B. The client should wear a protective covering over the stoma when showering.
- C. The client should clean the stoma and then apply a petroleum-based ointment.
- D. The client should use a humidifier in the room.
- E. The client can get a special telephone for communication.
Correct Answer: B,D,E
Rationale: Showering protection (B), humidifiers (D), and special phones (E) support tracheostomy care. Speech (A) is lost permanently, and petroleum ointment (C) risks infection.