A nurse is reinforcing discharge teaching with a client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching?
I will reschedule any body piercings if I have a fever.
I will notify my doctor before I have dental procedures.
I will floss my teeth twice a day as a part of my oral care.
I will wear a mask when I go out in public.
The Correct Answer is B
Choice A reason: This is an incorrect statement, because the client should avoid any body piercings, tattoos, or other procedures that can cause skin or mucosal trauma and increase the risk of bacterial infection and endocarditis. The client should also seek medical attention if they have a fever or other signs of infection.
Choice B reason: This is a correct statement, because the client should notify their doctor before they have dental procedures, such as cleaning, filling, or extraction, that can cause bleeding and introduce bacteria into the bloodstream. The client may need prophylactic antibiotics to prevent endocarditis.
Choice C reason: This is a partially correct statement, because the client should floss their teeth twice a day as a part of their oral care, but this is not enough to prevent recurrence of endocarditis. The client should also brush their teeth with a soft toothbrush after each meal, use an antiseptic mouthwash, and visit their dentist regularly.
Choice D reason: This is an unnecessary statement, because the client does not need to wear a mask when they go out in public, unless they have a respiratory infection or are exposed to someone who has one. Endocarditis is not transmitted by airborne or droplet routes, but by direct contact with the infected heart valves or blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.
Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.
Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.
Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.
Correct Answer is A
Explanation
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.
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