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. Hypertension. Filgrastim, a granulocyte colony-stimulating factor (G-CSF), primarily stimulates white blood cell production. While minor blood pressure fluctuations can occur, hypertension is not a common or significant adverse effect. Monitoring blood pressure is important, but sustained hypertension is not expected.

B. Fluid retention. Filgrastim does not typically cause significant fluid retention. Medications such as corticosteroids or certain chemotherapeutic agents are more likely to lead to fluid overload. While rare cases of capillary leak syndrome have been reported, general fluid retention is not a primary concern.

C. Bone pain. Bone pain is the most common adverse effect of filgrastim. The medication stimulates bone marrow activity, leading to increased production of neutrophils, which can cause discomfort in bones, particularly in long bones such as the femur and sternum. Pain is usually mild to moderate and can be managed with acetaminophen or NSAIDs if appropriate.

D. Hypokalemia. Filgrastim does not have a direct effect on potassium levels. Electrolyte imbalances are more commonly associated with diuretics, corticosteroids, or chemotherapy. Clients on filgrastim typically do not require routine potassium monitoring unless other risk factors are present.

A. Increase fluid intake B. Decrease sodium intake C. Eat foods high in potassium D. Take the medication 1 hr before meals.

Correct Answer is A

Explanation

A. Increase fluid intake. Clients taking lithium should increase fluid intake to 2-3 litres per day to prevent dehydration and maintain proper lithium excretion. Lithium is excreted by the kidneys, and dehydration can lead to toxic accumulation in the body. Adequate hydration also helps reduce the risk of side effects such as nephrotoxicity and lithium-induced polyuria.

B. Decrease sodium intake. Clients should not decrease sodium intake while on lithium. A low-sodium diet increases lithium reabsorption in the kidneys, leading to a higher risk of lithium toxicity. Instead, sodium intake should remain consistent, and clients should avoid excessive sodium restriction or sudden dietary changes.

C. Eat foods high in potassium. Potassium levels are not significantly affected by lithium therapy. While potassium is essential for overall health, increasing potassium intake is not a specific recommendation for lithium users. Potassium-rich foods are more relevant for clients taking diuretics (e.g., furosemide) or cardiac medications like digoxin.

D. Take the medication 1 hr before meals. Lithium is typically taken with food or milk to minimize gastrointestinal irritation. Taking it on an empty stomach can increase the likelihood of nausea and gastric discomfort, making it harder for clients to adhere to treatment. Clients should follow their provider’s instructions regarding meal timing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for lithium. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

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