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?

"This is an expected adverse effect of the medication.”

"Stop taking the medication. You are having an allergic reaction.

"This condition will only last a couple of days."

"Taking the medication with red meat will cause this adverse effect."

Answer and Explanation

The Correct Answer is A

A. "This is an expected adverse effect of the medication." Rifampin commonly causes red-orange discoloration of bodily fluids, including saliva, tears, urine, and sweat. This occurs due to the drug's excretion and is harmless. It does not indicate internal bleeding or organ dysfunction. Clients should be educated about this side effect in advance to prevent alarm and unnecessary discontinuation of the medication, as adherence to tuberculosis treatment is crucial.

B. "Stop taking the medication. You are having an allergic reaction." The red discoloration caused by rifampin is a known side effect, not an allergic reaction. A true allergic response would include symptoms such as rash, itching, swelling, or difficulty breathing. Stopping rifampin without medical advice could disrupt tuberculosis treatment, leading to drug resistance or treatment failure, making this an inappropriate recommendation.

C. "This condition will only last a couple of days." The discoloration of bodily fluids persists throughout the duration of rifampin therapy. Tuberculosis treatment can last several months, so the client should expect this effect to continue as long as they are taking the medication. Providing incorrect information may cause the client to worry unnecessarily when the discoloration does not resolve quickly.

D. "Taking the medication with red meat will cause this adverse effect." The discoloration is due to rifampin’s chemical properties and metabolism, not dietary intake. Red-colored foods, such as red meat or berries, do not influence this effect. Providing inaccurate dietary information may lead to unnecessary dietary restrictions, which are not needed for managing this side effect.

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Correct Answer is C

Explanation

A. Tinnitus. Nitrofurantoin is not commonly associated with ototoxicity or tinnitus. Medications such as aminoglycosides and loop diuretics are more likely to cause this adverse effect. While nitrofurantoin can have some neurological side effects, tinnitus is not a primary concern.

B. Abdominal cramping. Gastrointestinal side effects such as nausea and vomiting can occur with nitrofurantoin, especially if taken on an empty stomach. However, abdominal cramping is usually mild and not a serious adverse effect requiring discontinuation of the medication. Taking the drug with food can help reduce gastrointestinal discomfort.

C. Stevens-Johnson syndrome. Stevens-Johnson syndrome (SJS) is a rare but serious hypersensitivity reaction that can occur with nitrofurantoin use. It presents with flu-like symptoms, followed by a painful rash, blistering, and skin peeling. Immediate discontinuation and medical intervention are required if symptoms develop, as SJS can be life-threatening.

D. Insomnia. Nitrofurantoin does not commonly cause insomnia. Some medications, such as corticosteroids and stimulants, are more likely to interfere with sleep. Nitrofurantoin’s side effects primarily affect the gastrointestinal, pulmonary, and dermatologic systems rather than sleep patterns.

A. Client is short of breath B. intercostal retractions visible C. Wheezing auscultated throughout lung fields D. Diffuse, raised rash present on trunk E. Respiratory rate 30/min F. Blood pressure 90/55 mmHg G. Oxygen saturation 91% on room air H. Temperature 38.3°C (101°F) I. Client is alert and oriented to person, place, and time. J. Heart rate 110/min

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a new prescription for nitrofurantoin to treat a urinary tract infection. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

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