A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?
Red-orange discoloration of urine
Increased ecchymosis
Yellow appearance of the sclerae
Lack of energy
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.
Choice B reason:Option B (warm compresses)is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.
Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.
Choice D reason:Thefirst stepin the nursing process isassessment. Even with a diagnosis of blepharitis, the nurse mustinspect the eyesto evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.
Correct Answer is D
Explanation
Choice A reason: This is a normal finding, not an indication of breast cancer. Lumps that are mobile and tender upon palpation prior to a menstrual period are usually benign and related to hormonal changes.
Choice B reason: This is a normal finding, not an indication of breast cancer. Multiple round masses that are tender and found in both breasts are usually benign and related to fibrocystic breast changes.
Choice C reason: This is a normal finding, not an indication of breast cancer. Bilaterally darkened areolas are usually benign and related to genetic factors, pregnancy, or aging.
Choice D reason: This is an abnormal finding, and an indication of breast cancer. A nontender hard lump that is palpated in one breast is usually malignant and related to abnormal cell growth.
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