Nokea
You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?
- A. Ethambutol
- B. Streptomycin
- C. Isoniazid
- D. Rifampin
Correct Answer: D
Rationale: Rifampin commonly causes orange discoloration of body fluids (sweat, urine, tears) as a harmless side effect, and patients should be educated to expect this.
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The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?
Correct Answer: 880
Rationale: Heparin rate: (20,000 units ÷ 500 mL) × 22 mL/hr = 40 units/mL × 22 mL/hr = 880 units/hr.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
- A. The client's urine output is 100 mL in four (4) hours.
- B. The pulse oximeter reading is greater than 95%.
- C. The client has asymmetrical chest expansion.
- D. The telemetry reading shows sinus tachycardia.
Correct Answer: C
Rationale: Asymmetrical chest expansion (C) suggests pneumothorax, a ventilator complication. Low urine (A), SpO2 >95% (B), and tachycardia (D) are unrelated or expected.
Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT)
- C. Complete blood count (CBC) and hematocrit
- D. White blood cell (WBC) count and urinalysis
Correct Answer: B
Rationale: Liver function tests (AST and ALT) are essential before starting tuberculosis prophylaxis, as drugs like isoniazid can cause hepatotoxicity.
Which referral is most appropriate for a client diagnosed with end-stage COPD?
- A. The Asthma Foundation of America.
- B. The American Cancer Society.
- C. The American Lung Association.
- D. The American Heart Association.
Correct Answer: C
Rationale: The American Lung Association (C) supports COPD patients with resources. Asthma Foundation (A), Cancer Society (B), and Heart Association (D) are less relevant.
Immediately after the specimen is drawn, the registered nurse instructs the licensed practical nurse to perform which essential action?
- A. Apply direct pressure to the site for 5 minutes.
- B. Warm the blood in the specimen tube for 5 minutes.
- C. Assess the client's blood pressure in 5 minutes.
- D. Elevate the client's arm for at least 5 minutes.
Correct Answer: A
Rationale: Applying direct pressure to the radial artery puncture site for 5 minutes prevents bleeding and hematoma formation.