Nokea
The client taking rifampin brings a sample of urine that is orange in color to the clinic. Which interventions should the nurse implement? Select all that apply.
- A. Send the urine to the lab for culture and sensitivity (C&S).
- B. Reassure the client that this is normal and harmless.
- C. Teach that the urine that is orange can stain clothing.
- D. Question continuation of rifampin with the HCP.
- E. Inform that sweat and tears can also turn orange-colored.
Correct Answer: B,C,E
Rationale: A: A C&S is unnecessary because orange-colored urine is a normal finding in the client taking rifampin. B: The nurse should reassure the client that orange-colored urine is a normal finding in the client taking rifampin (Rifadin). C: The nurse should teach the client that the orange-colored urine and sweat can stain clothing and that the client should consider wearing nonwhite clothing or using undergarments if sweating is excessive. D: It is unnecessary to question continuation of rifampin if the urine is orange-colored because this is a normal finding. E: The nurse should inform the client that other body fluids, such as tears, sweat, and saliva, can also turn orange-colored with the use of rifampin (Rifadin).
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The nurse is assessing the 13-year-old who has been taking somatropin recombinant. Which findings should the nurse report to an HCP?
- A. Erythematous palmar rash
- B. Blood pressure of 122/74 mm Hg
- C. Random blood glucose of 158 mg/dL
- D. X-ray report noting epiphyseal closure
Correct Answer: D
Rationale: A: Erythematous palmar rash is not associated with the use of GH. B: BP of 122/74 in a 13-year-old is considered normal. C: Although GH use may be associated with blood glucose changes, a random blood glucose of 158 mg/dL is normal. D: Somatropin (Genotropin) recombinant is an injectable GH indicated for children with a deficiency of the hormone. It cannot be given once the epiphyses have closed. The nurse should notify the HCP.
Which of the following is true when administering a nasal spray medication?
- A. The client should blow their nose gently before the medication is administered.
- B. The medication should be sprayed in front of the nose.
- C. The medication should be administered as the patient exhales.
- D. The client should lay flat when the medication is administered.
Correct Answer: A
Rationale: The client should blow their nose gently before the medication is administered. This is to clear the nasal passages to allow the medication to be properly administered. When administering the medication, the client should sit upright, insert the applicator into the designated nostril, and spray the medication as the patient inhales.
The client is receiving fludrocortisone for treatment of adrenocortical insufficiency. The nurse is evaluating the client's serum laboratory values for adverse effects of the medication. Place an X in the column indicated for the laboratory values that the nurse should specifically review to evaluate the adverse effects of fludrocortisone. Select all that apply.
- A. Glucose
- B. TSH
- C. Potassium
- D. Platelets
- E. FreeT4
- F. Calcium
Correct Answer: A,C,D,F
Rationale: Adverse effects of fludrocortisone (Florinef) include hyperglycemia, hypokalemia, hypocalcemia, and thrombocytopenia. The nurse should review serum glucose, potassium, calcium, and platelet counts. Thyroid hormones of TSH and free T4, although abnormal, are unaffected by fludrocortisone administration.
A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct Answer: B
Rationale: A client taking an MAO Inhibitor, such as phenelzine (Nardil), should avoid tyramine-rich foods, which includes avocados, bananas, and salami.
The client is taking methylphenidate sustained-release tablets once daily for attention deficit disorder. The medication peaks in 4 to 7 hours and has a duration of 12 hours. At which time should the nurse instruct the client to take the prescribed dose of methylphenidate?
- A. At bedtime
- B. With the midday meal
- C. Six hours before bedtime
- D. Upon waking in the morning
Correct Answer: D
Rationale: Sustained-release methylphenidate (Ritalin) should be taken in the morning to avoid sleep interference.