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The nurse is reviewing the client's prescriptions.

Exhibits

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 tendency

Insomnia

Genitourinary

Darkening of the urine

Urinary frequency

Yellowing of the eyes

Blurred vision

Dry eyes

Abdominal pain

Weight gain

Increased bruising

Increased bleeding tendency

Insomnia

Darkening of the urine

Urinary frequency

Answer and Explanation

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

Rationale for Correct Options:

Yellowing of the eyes: Indicates hepatotoxicity, a serious adverse effect of isoniazid, rifampin, and pyrazinamide. These drugs can cause liver damage, leading to jaundice, which presents as yellowing of the eyes and skin. Liver function tests should be monitored closely.
Blurred vision: Can result from optic neuritis, a known adverse effect of ethambutol. Ethambutol can damage the optic nerve, causing visual disturbances, including decreased visual acuity and color blindness. Patients should undergo routine eye exams.
Abdominal pain: May indicate hepatotoxicity from TB medications, particularly isoniazid, rifampin, and pyrazinamide. Liver inflammation or damage can manifest as right upper quadrant pain, nausea, and loss of appetite. Monitoring liver enzymes is essential.
Increased bruising: Can result from thrombocytopenia, a hematologic side effect of rifampin. Rifampin can suppress bone marrow function, leading to reduced platelet production, increasing the risk of spontaneous bruising and prolonged bleeding.
Increased bleeding tendency: Suggests liver dysfunction, as the liver is responsible for producing clotting factors. Rifampin-induced hepatotoxicity can impair clotting mechanisms, increasing the risk of excessive bleeding from minor injuries.
Darkening of the urine: A common but harmless side effect of rifampin. Rifampin is excreted in bodily fluids, causing orange or red discoloration of urine, sweat, and tears. Patients should be educated on this expected effect to prevent unnecessary concern.

Rationale for Incorrect Options:

Dry eyes: Not associated with TB medications and may be due to environmental factors or dehydration.
Weight gain: Unlikely with TB treatment, as these medications typically cause weight loss rather than weight gain.
Insomnia: Not a significant adverse effect of first-line TB drugs and may be related to the client’s illness or other factors.
Urinary frequency: Not a common reaction to TB medications, as these drugs do not significantly affect renal function or bladder activity.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Ask the provider to spell out the name of the medication. Asking the provider to spell out the name of the medication is important to ensure accuracy and prevent medication errors. This step helps clarify any potential confusion regarding similar-sounding medications or names, reducing the risk of administering the wrong drug.
B. Withhold the medication until the provider signs the prescription. Withholding the medication until the provider signs the prescription is not necessary. Telephone prescriptions are valid and can be administered after being documented appropriately, provided that the nurse follows institutional policies regarding the signing of prescriptions. This means that the nurse should not delay necessary medication administration based on awaiting a signature.
C. Record the date and time of the telephone prescription. Recording the date and time of the telephone prescription is essential for accurate medical documentation. This information is critical for maintaining an accurate medication administration record and for legal purposes, ensuring that there is a clear timeline of the prescription order.
D. Request that the provider confirm the read-back of the prescription. Requesting that the provider confirm the read-back of the prescription is a crucial step in ensuring the accuracy of the prescription. The read-back method helps confirm that the nurse understood the prescription correctly and prevents potential errors by allowing the provider to verify the information relayed.
E. Instruct another nurse to record the prescription in the medical record. Instructing another nurse to record the prescription in the medical record is not appropriate. The nurse who received the telephone prescription should document it to maintain accountability and ensure accurate record-keeping. This promotes responsible practice and avoids miscommunication regarding the prescription details.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The preschooler is at risk for developing atelectasis evidenced by the preschooler's refusal to use the spirometer.

Atelectasis, or lung collapse, is a common postoperative complication due to shallow breathing and inadequate lung expansion. In this case the child refuses to use the incentive spirometer, which is crucial for preventing atelectasis by encouraging deep breathing. Shallow respirations are noted in both assessments, indicating reduced lung expansion.

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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 tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is assisting with the care of a preschooler who is postoperative following an appendectomy. Exhibits Complete the following sentence by using the lists of options. The preschooler is at risk for developing dropdownevidenced by the preschooler'sdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

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