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 D

Explanation

A. "If my pain is not relieved in 20 minutes, I will take a second tablet." Sublingual nitroglycerin should be taken at 5-minute intervals, up to a maximum of three doses within 15 minutes. If chest pain persists after three doses, emergency medical assistance is necessary, as this may indicate a myocardial infarction. Delaying a second dose for 20 minutes may lead to worsening of the condition and delay appropriate treatment.

B. "I will keep my tablets on a shelf in the bathroom." Nitroglycerin is highly sensitive to heat, light, and moisture, which can cause it to lose potency. Storing it in the bathroom, where temperature and humidity fluctuate, can degrade the medication. It should be kept in its original dark glass container with the lid tightly closed and stored in a cool, dry place away from moisture and heat sources.

C. "I should be sure to swallow the tablet whole." Sublingual nitroglycerin is designed to dissolve under the tongue for rapid absorption into the bloodstream. Swallowing it whole delays its effect because it would need to pass through the digestive system before being absorbed, reducing its ability to quickly relieve angina. Clients should be instructed to place the tablet under the tongue and allow it to dissolve completely without chewing or swallowing.

D. “If my mouth is dry, I will take a sip of water before I take the tablet.” A dry mouth can slow the dissolution of the sublingual tablet, delaying its absorption and effectiveness. Taking a sip of water before administration ensures the tablet dissolves properly under the tongue, allowing for rapid relief of angina symptoms. However, clients should avoid drinking excessive amounts of water that might wash the tablet down before it dissolves.

A. Increase fluid intake B. Decrease sodium intake C. Eat foods high in potassium D. Take the medication 1 hr before meals.

Correct Answer is A

Explanation

A. Increase fluid intake. Clients taking lithium should increase fluid intake to 2-3 litres per day to prevent dehydration and maintain proper lithium excretion. Lithium is excreted by the kidneys, and dehydration can lead to toxic accumulation in the body. Adequate hydration also helps reduce the risk of side effects such as nephrotoxicity and lithium-induced polyuria.

B. Decrease sodium intake. Clients should not decrease sodium intake while on lithium. A low-sodium diet increases lithium reabsorption in the kidneys, leading to a higher risk of lithium toxicity. Instead, sodium intake should remain consistent, and clients should avoid excessive sodium restriction or sudden dietary changes.

C. Eat foods high in potassium. Potassium levels are not significantly affected by lithium therapy. While potassium is essential for overall health, increasing potassium intake is not a specific recommendation for lithium users. Potassium-rich foods are more relevant for clients taking diuretics (e.g., furosemide) or cardiac medications like digoxin.

D. Take the medication 1 hr before meals. Lithium is typically taken with food or milk to minimize gastrointestinal irritation. Taking it on an empty stomach can increase the likelihood of nausea and gastric discomfort, making it harder for clients to adhere to treatment. Clients should follow their provider’s instructions regarding meal timing.

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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?

Nursing Test Bank

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A nurse is reinforcing teaching with a client who has angina and a new prescription of nitroglycerin sublingual. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for lithium. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

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