A nurse assisting with the care of a client who is admitted to the medical-surgical unit.

The nurse is reviewing the client's laboratory findings and vital signs.

Select the 5 findings that require immediate follow-up.

A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.

B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.

C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.

D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.

A. "I can expect my contact lenses to turn red or orange.”
Rifampin causes red-orange discoloration of body fluids, including tears, sweat, urine, and saliva. This effect is harmless but can stain soft contact lenses permanently, so clients should be advised to use glasses instead.

B. “I should notify my provider if I start taking new over-the-counter or prescription medications.”
Rifampin is a potent enzyme inducer that can alter the metabolism of many drugs, including oral contraceptives and anticoagulants. The provider should be informed of any new medications to avoid potential drug interactions and ensure therapeutic effectiveness.

C. “I will need to have someone observe me when I take my medication.”
Directly observed therapy (DOT) is recommended to ensure adherence to tuberculosis treatment. A healthcare provider or designated individual supervises medication intake to improve compliance and reduce the risk of drug resistance.

D. “I will need to have a repeat Mantoux test in 4 weeks.”
A repeat Mantoux test is unnecessary for diagnosing active tuberculosis, as this condition is confirmed through sputum cultures and chest X-ray findings. Mantoux testing is primarily used for screening latent TB infections.

E. “I am no longer contagious.”
Clients with active tuberculosis remain contagious until they complete at least two weeks of effective multidrug therapy and show clinical improvement. Until then, infection control measures such as respiratory isolation should be followed.

F. “I will need to take my medications for a total of 6 weeks.”
The standard treatment for active tuberculosis lasts at least six months, typically involving a four-drug regimen for the first two months, followed by two drugs for the remaining four months. A six-week course is insufficient for eradication.

G. "I can continue my current alcohol intake."
Alcohol should be avoided due to the hepatotoxic effects of isoniazid, rifampin, and pyrazinamide. Combining alcohol with these medications increases the risk of liver damage, requiring clients to abstain or limit intake.