The nurse is aware that the client who is prescribed medications for tuberculosis should have which laboratory test(s) assessed monthly?

Liver function studies.

White blood cells (WBCs).

Coagulation studies.

Red blood cells (RBCs).

Answer and Explanation

The Correct Answer is A

Clients on tuberculosis (TB) medications, particularly those on isoniazid, rifampin, and pyrazinamide, are at risk for hepatotoxicity. Therefore, regular monitoring of liver function tests (LFTs) is crucial to detect any liver damage early and adjust treatment as necessary.

Choice A reason:

Liver function studies are essential for clients on TB medications. Drugs like isoniazid, rifampin, and pyrazinamide can cause liver toxicity. Monitoring liver enzymes such as ALT (alanine aminotransferase) and AST (aspartate aminotransferase) helps in early detection of hepatotoxicity, allowing for timely intervention to prevent severe liver damage. Regular LFTs ensure that any adverse effects on the liver are identified and managed promptly.

Choice B reason:

White blood cells (WBCs) are not typically monitored monthly for clients on TB medications. While WBC counts can be affected by various conditions and treatments, they are not specifically indicative of the side effects of TB medications. Monitoring WBCs might be necessary if there are signs of infection or other hematologic issues, but it is not a standard monthly requirement for TB treatment.

Choice C reason:

Coagulation studies are not routinely required for clients on TB medications. These tests are more relevant for patients on anticoagulant therapy or those with bleeding disorders. TB medications do not typically affect coagulation parameters, so regular monitoring of coagulation studies is not necessary unless there is a specific clinical indication.

Choice D reason:

Red blood cells (RBCs) are also not typically monitored monthly for clients on TB medications. While anemia can occur in TB patients, it is not a direct side effect of the medications used to treat TB. Monitoring RBCs might be necessary if there are symptoms of anemia or other hematologic concerns, but it is not a standard part of monthly TB treatment monitoring.

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Correct Answer is ["B","C"]

Explanation

Choice A reason: Listening to at least one full respiration in each location is a proper technique for respiratory assessment. It ensures that the nurse can accurately assess the breath sounds and identify any abnormalities. This method allows for a thorough evaluation of the respiratory system, ensuring that no areas are missed.

Choice B reason: Instructing the client to breathe in and out rapidly while listening to breath sounds is incorrect. Rapid breathing can lead to hyperventilation and may not provide an accurate representation of the client’s normal breath sounds. The proper technique is to instruct the client to take slow, deep breaths through their mouth, which allows for a more accurate assessment of the breath sounds and any potential abnormalities.

Choice C reason: Listening to breath sounds through the hospital gown or clothing is incorrect. Clothing can interfere with the sounds and may lead to inaccurate assessments. The proper technique is to place the stethoscope directly on the client’s skin to ensure that the breath sounds are heard clearly and accurately.

Choice D reason: Instructing the client to take slow deep breaths through his or her nose is partially correct but not ideal. While slow deep breaths are appropriate, they should be taken through the mouth to ensure that the breath sounds are more pronounced and easier to assess. Breathing through the nose can sometimes muffle the sounds and make it harder to detect abnormalities.

Choice E reason: Listening as the client inhales and then moving to the next site during exhalation is incorrect. The nurse should listen to both the inhalation and exhalation phases of respiration at each site. This ensures a complete assessment of the breath sounds and helps in identifying any abnormalities that may be present during either phase of respiration.

A. Increase the client’s intake of Vitamin C. B. Teach the client to splint the incision when coughing. C. Have the client do abdominal exercises. D. Perform passive range of motion exercises.

Correct Answer is B

Explanation

Choice A Reason:

Increasing the client’s intake of Vitamin C can help with wound healing due to its role in collagen formation. However, this is not an immediate action to prevent wound dehiscence. While important for overall recovery, it does not directly address the mechanical stress on the incision site that can lead to dehiscence.

Choice B Reason:

Teaching the client to splint the incision when coughing is the most effective immediate action to prevent wound dehiscence. Splinting provides support to the incision site, reducing the risk of the wound opening due to the pressure exerted during coughing or other activities that increase intra-abdominal pressure. This method directly addresses the mechanical stress that can cause dehiscence.

Choice C Reason:

Having the client do abdominal exercises is not appropriate in the immediate postoperative period as it can increase the risk of wound dehiscence. Abdominal exercises can put additional strain on the incision site, potentially leading to separation of the wound edges.

Choice D Reason:

Performing passive range of motion exercises is beneficial for preventing complications such as joint stiffness and muscle atrophy. However, it does not specifically address the prevention of wound dehiscence. These exercises do not provide the necessary support to the incision site to prevent it from opening.

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The nurse is aware that the client who is prescribed medications for tuberculosis should have which laboratory test(s) assessed monthly?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The experienced nurse understands that the student nurse may require additional instruction regarding proper respiratory assessment techniques when the nurse observes the student: (SELECT ALL THAT APPLY)

Correct Answer is ["B","C"]

Explanation

Which nursing action should the nurse implement to prevent wound dehiscence in the postoperative client?

Correct Answer is B

Explanation

The nurse is changing a client’s abdominal dressing and notes a separation of the incision line. The underlying tissue is protruding from the wound. The nurse should plan to do which of the following in the initial care of this wound?

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The nurse recognizes that the client is manifesting early signs of hypoxia with findings of:

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