A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.

Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.

Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.

Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.

Choice A reason: This is the correct finding, because rifampin is an antibiotic that can cause red-orange discoloration of urine, saliva, sweat, tears, and other body fluids. This is a harmless and expected adverse effect of rifampin, and does not indicate any damage to the kidneys or liver. The client should be informed about this effect and advised to wear soft contact lenses, as rifampin can stain them permanently.

Choice B reason: This is an incorrect finding, because increased ecchymosis, or bruising, is not a harmless or expected adverse effect of rifampin, but a sign of bleeding disorder or thrombocytopenia, which is a rare but serious complication of rifampin. Rifampin can interfere with the synthesis of vitamin K, which is essential for blood clotting, and cause bleeding problems. The client should report any signs of bleeding, such as ecchymosis, petechiae, hematuria, or epistaxis, to the provider.

Choice C reason: This is an incorrect finding, because yellow appearance of the sclerae, or jaundice, is not a harmless or expected adverse effect of rifampin, but a sign of liver damage or hepatitis, which is a rare but serious complication of rifampin. Rifampin can cause inflammation and injury to the liver cells, and impair the metabolism and excretion of bilirubin, which is a yellow pigment that accumulates in the skin and eyes when the liver is damaged. The client should report any signs of liver dysfunction, such as jaundice, dark urine, pale stools, or abdominal pain, to the provider.

Choice D reason: This is an incorrect finding, because lack of energy, or fatigue, is not a harmless or expected adverse effect of rifampin, but a sign of anemia or hypothyroidism, which are rare but serious complications of rifampin. Rifampin can cause hemolytic anemia, which is a condition that occurs when the red blood cells are destroyed faster than they are produced, and hypothyroidism, which is a condition that occurs when the thyroid gland produces insufficient thyroid hormone. The client should report any signs of anemia or hypothyroidism, such as fatigue, weakness, pallor, or cold intolerance, to the provider.