A nurse in a clinic receives a telephone call from a client who has tuberculosis and was prescribed rifampin 3 days ago. The client reports, "My saliva and tears are red. What should I do?" Which of the following responses by the nurse is appropriate?

"This is an expected adverse effect of the medication.”

"Stop taking the medication. You are having an allergic reaction.

"This condition will only last a couple of days."

"Taking the medication with red meat will cause this adverse effect."

Answer and Explanation

The Correct Answer is A

A. "This is an expected adverse effect of the medication." Rifampin commonly causes red-orange discoloration of bodily fluids, including saliva, tears, urine, and sweat. This occurs due to the drug's excretion and is harmless. It does not indicate internal bleeding or organ dysfunction. Clients should be educated about this side effect in advance to prevent alarm and unnecessary discontinuation of the medication, as adherence to tuberculosis treatment is crucial.

B. "Stop taking the medication. You are having an allergic reaction." The red discoloration caused by rifampin is a known side effect, not an allergic reaction. A true allergic response would include symptoms such as rash, itching, swelling, or difficulty breathing. Stopping rifampin without medical advice could disrupt tuberculosis treatment, leading to drug resistance or treatment failure, making this an inappropriate recommendation.

C. "This condition will only last a couple of days." The discoloration of bodily fluids persists throughout the duration of rifampin therapy. Tuberculosis treatment can last several months, so the client should expect this effect to continue as long as they are taking the medication. Providing incorrect information may cause the client to worry unnecessarily when the discoloration does not resolve quickly.

D. "Taking the medication with red meat will cause this adverse effect." The discoloration is due to rifampin’s chemical properties and metabolism, not dietary intake. Red-colored foods, such as red meat or berries, do not influence this effect. Providing inaccurate dietary information may lead to unnecessary dietary restrictions, which are not needed for managing this side effect.

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Correct Answer is C

Explanation

A. Deferoxamine. Deferoxamine is a chelating agent used to treat iron overload or toxicity. It has no role in managing an acute allergic reaction or respiratory distress caused by nafcillin, a penicillin-type antibiotic.

B. Vitamin K. Vitamin K is used to reverse the effects of warfarin-induced anticoagulation and is not indicated for treating an allergic reaction. Anaphylaxis is not related to coagulation disturbances, making this an inappropriate intervention.

C. Epinephrine. Epinephrine is the first-line treatment for anaphylaxis, which can present with difficulty breathing, bronchospasm, and hypotension. It works by stimulating alpha- and beta-adrenergic receptors, leading to bronchodilation, increased cardiac output, and vasoconstriction to counteract severe allergic reactions. Immediate administration is necessary to prevent further airway compromise and circulatory collapse.

D. Prednisone. Prednisone is a corticosteroid used to reduce inflammation and prevent delayed allergic reactions. While it may be prescribed as part of long-term management, it does not provide the rapid bronchodilation and vasoconstriction needed for emergency treatment of anaphylaxis.

A. A pregnant parent B. Receiving treatment for leukemia C. Taking acetaminophen for mild discomfort D. An allergy to eggs

Correct Answer is B

Explanation

A. A pregnant parent. A child can receive the varicella vaccine even if the parent is pregnant. While the varicella vaccine is a live attenuated vaccine, the vaccinated child does not pose a significant risk of transmission to others. The parent should avoid direct contact with the vaccinee's rash if one develops, but this is not a contraindication to immunization.

B. Receiving treatment for leukemia. Children undergoing treatment for leukemia often have weakened immune systems due to chemotherapy or radiation. The varicella vaccine is a live attenuated vaccine, meaning it contains a weakened form of the virus that could cause severe illness in immunocompromised individuals. These children should not receive live vaccines until their immune function improves and their healthcare provider approves vaccination.

C. Taking acetaminophen for mild discomfort. Acetaminophen is an over-the-counter pain reliever and fever reducer that does not interfere with the efficacy or safety of the varicella vaccine. There is no evidence that mild analgesic use before or after vaccination affects immune response, so it is not a reason to withhold the immunization.

D. An allergy to eggs. Unlike some influenza and yellow fever vaccines, the varicella vaccine is not produced using egg-based components. An egg allergy is not a contraindication to receiving the varicella vaccine, as it does not contain egg proteins.

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A nurse in a clinic receives a telephone call from a client who has tuberculosis and was prescribed rifampin 3 days ago. The client reports, "My saliva and tears are red. What should I do?" Which of the following responses by the nurse is appropriate?

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A nurse in a clinic receives a telephone call from a client who has tuberculosis and was prescribed rifampin 3 days ago. The client reports, "My saliva and tears are red. What should I do?" Which of the following responses by the nurse is appropriate?