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 ["B","C"]

Explanation

A. Breastfeeding. Ceftriaxone is generally considered safe during breastfeeding because only a small amount is excreted in breast milk. While monitoring for gastrointestinal disturbances or thrush in the infant is advised, breastfeeding is not a contraindication for ceftriaxone use.

B. Client allergy. The client has a penicillin allergy, which raises concerns about cross-reactivity with cephalosporins, including ceftriaxone. Although the cross-reactivity rate is low, clients with a history of severe allergic reactions (e.g., anaphylaxis, angioedema, or urticaria) to penicillin should avoid cephalosporins. The nurse should clarify the nature of the penicillin allergy before administering ceftriaxone.

C. Gentamycin prescription. Ceftriaxone and gentamicin are both nephrotoxic, and using them together increases the risk of kidney damage. The client should be monitored for renal function impairment, and alternative antibiotic therapy may be considered if necessary. The nurse should discuss this potential drug interaction with the provider before administration.

D. Hematocrit. The client’s hematocrit (32%) is low but does not require withholding ceftriaxone. A slightly decreased hematocrit is expected postpartum, especially in cases of infection or recent delivery. Ceftriaxone is not known to cause significant hematologic suppression that would make this a contraindication.

E. Hemoglobin. The client’s hemoglobin (9 g/dL) is lower than normal, likely due to postpartum blood loss or infection-related inflammation. However, ceftriaxone does not directly affect hemoglobin levels, so this is not a reason to withhold the medication.

A. Fluconazole B. Tetracycline C. Acyclovir D. Cephalexin

Correct Answer is D

Explanation

A. Fluconazole. Fluconazole is an antifungal medication used to treat fungal infections, such as candidiasis. It is not related to penicillin and does not pose a risk for cross-reactivity in clients with a penicillin allergy. It can be safely administered in this scenario.

B. Tetracycline. Tetracycline is a broad-spectrum antibiotic used to treat bacterial infections, including acne and respiratory infections. It belongs to a different antibiotic class than penicillins and cephalosporins, meaning it does not pose a risk of cross-reactivity in clients with a penicillin allergy.

C. Acyclovir. Acyclovir is an antiviral medication used to treat viral infections, such as herpes simplex and varicella-zoster. Since it does not belong to the beta-lactam antibiotic class, it is not contraindicated for clients with a penicillin allergy.

D. Cephalexin. Cephalexin is a first-generation cephalosporin, which shares a similar beta-lactam ring structure with penicillins. Clients with a history of an anaphylactic reaction to penicillin are at increased risk of cross-reactivity with cephalosporins, particularly first-generation ones like cephalexin. Due to the severity of the client’s allergic reaction, cephalexin should be avoided, and an alternative non-beta-lactam antibiotic should be considered.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is scheduled to receive a dose of ceftriaxone The nurse has reviewed the client's electronic medical record (EMR). Which of the following findings should the nurse recommend withholding the ceftriaxone? Select all that apply.

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

Explanation

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Correct Answer is D

Explanation

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