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The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.

Body system

Findings

Head. Eyes. Ears. Nose, and Throat (HEENT)

Yellowing of the eyes

Blurred vision

Dry eyes

Gastrointestinal

Abdominal pain

Weight gain

Hematologic

Increased bruising

Increased bleeding tendancies

Insomnia

Genitourinary

Darkening of the urine

Urinary frequency

A.

Yellowing of the eyes

B.

Blurred vision

C.

Dry eyes

D.

Abdominal pain

E.

Weight gain

F.

Increased bruising

G.

Increased bleeding tendancies

H.

Insomnia

I.

Darkening of the urine

J.

Urinary frequency

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","I"]

Yellowing of the eyes (Jaundice) → Isoniazid and Rifampin can cause hepatotoxicity, leading to jaundice.

Blurred vision → Ethambutol can cause optic neuritis, leading to blurred vision and color blindness.

Dry eyes (Incorrect) → Not a common side effect of TB medications.

Gastrointestinal:

 

Abdominal pain → Isoniazid, Rifampin, and Pyrazinamide are hepatotoxic and can cause liver inflammation and gastric irritation.

Weight gain (Incorrect) → TB medications are more likely to cause weight loss rather than gain.

Hematologic:

 

Increased bruising & bleeding tendencies → Rifampin can cause thrombocytopenia, increasing the risk of bruising and bleeding.

Insomnia (Incorrect) → Not a serious adverse effect of TB medications.

Genitourinary:

 

Darkening of the urine → Rifampin causes orange-red discoloration of urine, sweat, and tears, which is a benign but expected effect.

Urinary frequency (Incorrect) → Not a known adverse effect of TB medications.


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Related Questions

Correct Answer is C

Explanation

A) Client report of muscle spasms of the left leg: Muscle spasms are common in clients with a cast, especially if the muscle is restricted for an extended period. While muscle spasms can be uncomfortable, they are not immediately life-threatening. The nurse should still address the discomfort but it does not take priority over other potential issues like circulation.
B) One fingerbreadth of space between the cast and the skin: A small amount of space between the cast and the skin can be normal and is typically observed in a well-applied cast. However, this finding alone does not indicate an immediate concern unless other signs such as swelling or impaired circulation are noted.

C) Diminished pulses on the affected extremity: Diminished pulses are a priority concern. This may indicate compromised circulation, which can lead to serious complications such as tissue ischemia or compartment syndrome. The nurse should immediately assess the severity of the circulation problem, as any signs of compromised blood flow require prompt intervention to prevent permanent damage or loss of limb function.

D) Ecchymosis on the inner left thigh: Ecchymosis or bruising on the inner thigh can be a normal consequence of trauma or injury related to the reason for the cast. While it is important to monitor for any changes in the condition, ecchymosis itself is not immediately life-threatening or urgent compared to potential circulation issues.

Correct Answer is ["30"]

Explanation

To calculate the drip rate, follow these steps:

  1. The client needs to receive 120 mL of lactated Ringer's over 1 hour (60 minutes).
  2. The IV tubing has a drip factor of 15 drops per mL (15 gtt/mL).
  3. Multiply the total volume (120 mL) by the drip factor (15 gtt/mL), which gives 1,800 drops.
  4. Divide this by the total time in minutes (60 minutes).

1,800 drops ÷ 60 minutes = 30 drops per minute (30 gtt/min)

Final Answer:

30 gtt/min

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