A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

"Your provider will prescribe a different medication regimen."

"This is an expected adverse effect of this medication."

"This finding may indicate possible medication toxicity."

"You will need to increase your fluid intake to resolve this problem."

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B.

Choice A rationale: This choice suggests that the provider will prescribe a different medication regimen. However, this is not necessarily the case. Rifampin is a first-line medication for tuberculosis and its side effects, including the discoloration of body fluids, are well-known and expected. Therefore, it is unlikely that the provider would change the medication regimen solely based on this side effect.

Choice B rationale: This is the correct answer. Rifampin, an antibiotic used to treat tuberculosis, can cause a harmless red-orange discoloration of body fluids, including urine, sweat, tears, and saliva. This is an expected side effect of the medication and does not indicate any harm or toxicity. It is important for the nurse to reassure the client that this is a normal occurrence and does not require any changes to the medication regimen.

Choice C rationale: This choice suggests that the red-orange discoloration of the client’s saliva may indicate possible medication toxicity. However, this is not accurate. While rifampin can have serious side effects, including liver damage and severe gastrointestinal upset, the discoloration of body fluids is not a sign of toxicity. It is a harmless side effect of the medication.

Choice D rationale: This choice suggests that the client will need to increase her fluid intake to resolve the problem. However, increasing fluid intake will not change the discoloration caused by rifampin. The discoloration is a result of the medication itself and is not influenced by the client’s hydration status.

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Correct Answer is D

Explanation

A flat lesion with irregular borders is one of the signs of melanoma, a type of skin cancer that arises from melanocytes, the cells that produce pigment. Other signs of melanoma include asymmetry, color variation, diameter greater than 6 mm, and evolution or change over time. The other options are more characteristic of other types of skin cancer or benign lesions.

A. Command the dog to sit while talking with the client. B. Consult the client before approaching the dog. C. Offer the dog a bowl of water to demonstrate caring. D. Pet the dog briefly to demonstrate acceptance.

Correct Answer is B

Explanation

The nurse should consult the client before approaching the dog, as the service animal is working and may have specific instructions from the handler on how to interact with others. The nurse should respect the client's autonomy and preferences regarding their service animal and not interfere with their bond or function.

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A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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