A nurse on a medicalsurgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis.
Which of the following findings should the nurse report to the provider?
Yellow sclera
Increasing AST level
Weight loss
Mantoux test result
Increasing ALT level
Reddishorange urine color
Correct Answer : A,B,E
A. Yellow sclera: This may indicate hepatotoxicity, a serious adverse effect of isoniazid and rifampin. The provider should be notified immediately to assess liver function and adjust medications if necessary.
B. Increasing AST level: The AST increased from 35 to 36 units/L, which is within the normal range but may suggest early signs of liver dysfunction, especially in combination with other findings like jaundice.
C. Weight loss: While weight loss is a symptom of tuberculosis (TB), the client reported a 3.2 kg (7 lb) loss before admission. Since this is an expected finding with TB, it does not necessarily require immediate provider notification unless it continues despite treatment.
D. Mantoux test result: A 12 mm induration is considered positive in highrisk populations but does not confirm active TB. Given that the client already has a chest Xray showing caseation, a positive skin test is not the most critical finding to report.
E. Increasing ALT level: The ALT increased from 36 to 38 SI/L, which is a slight rise but, along with the AST increase and jaundice, suggests possible liver dysfunction due to TB medications.
F. Reddishorange urine color: This is a normal side effect of rifampin and does not indicate harm. It does not require provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Protamine sulfate is the specific antidote for heparin toxicity, working by neutralizing heparin’s anticoagulant effects. It binds to heparin to form a stable complex, preventing excessive bleeding. It is administered intravenously (IV) in cases of heparin overdose or severe bleeding complications.
B. Vitamin K is the antidote for warfarin (Coumadin), not heparin. It promotes the synthesis of clotting factors II, VII, IX, and X, but it does not affect heparin’s mechanism of action, which works by inhibiting thrombin and factor Xa.
C. Deferasirox is an iron chelating agent used to treat iron overload in conditions like thalassemia or hemochromatosis. It does not reverse anticoagulation caused by heparin.
D. Acetylcysteine is primarily used to treat acetaminophen (Tylenol) overdose and as a mucolytic for respiratory conditions. It has no role in counteracting heparin’s effects.
Correct Answer is C
Explanation
A. Maintaining a semiFowler's position as often as possible. While positioning can aid in lung expansion and ease breathing, it does not directly help thin thick bronchial secretions. Proper hydration is more effective in loosening mucus and making it easier to expectorate.
B. Administering oxygen via nasal cannula at 2 L/min. Oxygen therapy is beneficial for COPD clients with hypoxemia, but it does not specifically address thick secretions. Oxygen at high levels can also suppress the respiratory drive in COPD patients, so it should be used cautiously.
C. Encouraging the client to drink 2 to 3 L of water daily. Adequate hydration helps thin tenacious bronchial secretions, making them easier to clear. Fluids reduce mucus viscosity, facilitating expectoration, which improves airway clearance and reduces coughing discomfort.
D. Helping the client select a lowsalt diet. A lowsodium diet can help with fluid balance, particularly in clients with heart failure or hypertension, but it does not directly affect mucus production or secretion viscosity in COPD patients.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.