An adult exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
Conversion of the client's PPD test from negative to positive
History of intravenous drug abuse
Current diagnosis of hepatitis B
Length of time of the exposure to tuberculosis
The Correct Answer is C
Choice A reason: Conversion of the client's PPD test from negative to positive is not the most important information for the nurse to note, as this is an expected finding for a client who has been exposed to tuberculosis and does not affect the administration of isoniazid. This is a distractor choice.
Choice B reason: History of intravenous drug abuse is not the most important information for the nurse to note, as this is not directly related to the use of isoniazid and does not contraindicate its administration. This is another distractor choice.
Choice C reason: Current diagnosis of hepatitis B is the most important information for the nurse to note, as this can increase the risk of hepatotoxicity and liver damage from isoniazid, which requires close monitoring and possible dose adjustment. Therefore, this is the correct choice.
Choice D reason: Length of time of the exposure to tuberculosis is not the most important information for the nurse to note, as this does not influence the dosage or frequency of isoniazid and does not indicate any complication or adverse reaction. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C reason: pushing the undiluted Dextrose slowly through the currently infusing IV is the best way to administer the medication for a client with insulin shock. Insulin shock is a condition in which the blood glucose level drops too low due to excess insulin or insufficient food intake. This can cause symptoms such as confusion, sweating, tremors, or loss of consciousness. The nurse should administer 50% Dextrose IV as a bolus injection to raise the blood glucose level quickly and prevent brain damage.
Choice A reason: asking the pharmacist to add the Dextrose to a TPN solution is not appropriate for a client with insulin shock. TPN stands for total parenteral nutrition, which is a type of intravenous feeding that provides all the nutrients needed by the body. TPN solutions contain dextrose, amino acids, lipids, vitamins, minerals, and electrolytes in specific concentrations and ratios. Adding extra dextrose to a TPN solution can alter its composition and cause complications such as hyperglycemia or fluid overload.
Choice B reason: mixing the Dextrose in a 50 mL piggyback for a total volume of 100 mL is not effective for a client with insulin shock. A piggyback is a type of intravenous infusion that delivers medication through a secondary tubing attached to the primary tubing of another solution. Mixing the Dextrose in a piggyback can dilute its concentration and reduce its potency. It can also delay its delivery and onset of action.
Choice D reason: diluting the Dextrose in one liter of 0.9% Normal Saline solution is not safe for a client with insulin shock. Normal Saline is a type of intravenous fluid that contains sodium chloride in isotonic concentration. Diluting the Dextrose in one liter of Normal Saline can lower its concentration and increase its volume significantly. This can cause complications such as hypoglycemia or fluid overload.
Correct Answer is ["B","C","D","E"]
Explanation
Choice B reason: monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause portal hypertension, which is an increased pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can lead to ascites, which is an accumulation of fluid in the abdominal cavity. The nurse should measure and record the abdominal girth daily and report any significant changes.
Choice C reason: reporting serum albumin and globulin levels is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can impair the synthesis of proteins, such as albumin and globulin, which are essential for maintaining fluid balance, immune function, and blood clotting. The nurse should monitor and report the serum albumin and globulin levels and administer supplements or transfusions as prescribed.
Choice D reason: noting signs of bleeding and edema is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Cirrhosis of the liver can cause coagulopathy, which is a disorder of blood clotting, due to reduced production of clotting factors and increased consumption of platelets. Coagulopathy can lead to bleeding from various sites, such as the gums, nose, esophagus, stomach, or rectum. The nurse should observe and report any signs of bleeding and apply pressure or bandages as needed. Cirrhosis of the liver can also cause hypoalbuminemia, which is a low level of albumin in the blood, due to decreased synthesis or increased loss of albumin. Hypoalbuminemia can lead to edema, which is swelling caused by fluid retention in the tissues. The nurse should assess and report any signs of edema and elevate the affected limbs or apply compression stockings as indicated.
Choice E reason: limiting fluid intake to 1500 mL daily is an important intervention for a client with cirrhosis of the liver and end stage liver disease. Fluid restriction can help prevent or reduce ascites and edema by decreasing the fluid load on the circulatory system and the kidneys. The nurse should measure and record the fluid intake and output and educate the client on how to limit their fluid intake.
Choice A reason: providing a diet low in phosphorus is not a specific intervention for a client with cirrhosis of the liver and end stage liver disease. A diet low in phosphorus may be indicated for clients with chronic kidney disease or hyperphosphatemia, but not for clients with cirrhosis of the liver. The nurse should provide a diet that is high in calories, carbohydrates, and protein, but low in sodium, fat, and alcohol for clients with cirrhosis of the liver.
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