Nokea
What is a common side effect of Rifampin concerning the client's contact lenses?
- A. The client's urine might turn blue.
- B. The client remains infectious to others for 48 hours.
- C. The client's contact lenses might be stained orange.
- D. The client's skin might take on a crimson glow.
Correct Answer: C
Rationale: The correct answer is that the client's contact lenses might be stained orange. Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained, making this an important side effect for the client to be aware of. Choices A, B, and D are incorrect. There is no documented effect of Rifampin causing the client's urine to turn blue, the client remaining infectious for 48 hours, or the client's skin taking on a crimson glow.
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Which of the following conditions has a severe complication of respiratory failure?
- A. Bell's palsy
- B. Guillain-Barré syndrome
- C. Trigeminal neuralgia
- D. Tetanus
Correct Answer: B
Rationale: Guillain-Barré syndrome is characterized by a severe complication of respiratory failure due to the involvement of the peripheral nerves that control breathing. While Bell's palsy, trigeminal neuralgia, and tetanus are also conditions affecting peripheral nerves, they do not typically lead to respiratory failure like Guillain-Barré syndrome. Bell's palsy causes facial muscle weakness, trigeminal neuralgia results in severe facial pain, and tetanus leads to muscle stiffness and spasms, but none of these conditions directly involve respiratory failure.
A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?
- A. 'I need to reapply spermicidal cream with repeated intercourse.'
- B. 'The diaphragm needs to be filled with spermicidal cream before insertion.'
- C. 'I can leave the diaphragm in place as long as I want after intercourse.'
- D. 'The diaphragm can be inserted as long as 6 hours before intercourse.'
Correct Answer: C
Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome. Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy. Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness. Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
- A. the client has been admitted to the hospital three times in the last 2 months.
- B. the client has a Foley catheter.
- C. the client's family is available to care for him 24 hours a day.
- D. the client is ordered to continue IV antibiotics 5 days post discharge.
Correct Answer: V
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.
If a visitor accidentally knocks over a plastic pleural drainage system connected to a client, causing it to crack, what should the nurse do first?
- A. Observe the client's response.
- B. Notify the physician.
- C. Change the drainage system.
- D. Observe for leaks.
Correct Answer: C
Rationale: When a pleural drainage system is cracked, the nurse's initial action should be to change the drainage system. This is essential to prevent potential complications like air leaks or infections. While observing the client's response and checking for leaks are important steps, they are secondary to addressing the immediate issue of the cracked system. Notifying the physician, though necessary, can be carried out once the primary concern of the damaged system is resolved.
A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?
- A. Notify the physician.
- B. Clamp the chest tube.
- C. Replace the system.
- D. Document the finding
Correct Answer: D
Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.