A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

Choice A Reason:

"This finding may indicate possible medication toxicity." - The red-orange colour change in bodily fluids from rifampin is not indicative of medication toxicity.

Choice B Reason:

"This is an expected adverse effect of this medication." Rifampin is an antibiotic commonly used to treat tuberculosis. One of the well-known side effects of rifampin is the discoloration of bodily fluids, including saliva, tears, sweat, and urine, to a red-orange colour. This is a harmless and expected adverse effect of the medication and is not a sign of toxicity or other serious concerns.

Choice C Reason:

"Your provider will prescribe a different medication regimen." - There is no need to change the medication regimen based solely on the colour change of bodily fluids. This is an expected effect of rifampin.

Choice D Reason:

"You will need to increase your fluid intake to resolve this problem." - Increasing fluid intake will not resolve the colour change caused by rifampin. The client should be educated about the benign nature of the side effects instead.

Choice A Reason:

Changing the catheter dressing daily - While it's important to maintain the dressing and keep it clean and dry, changing the dressing daily might not be necessary. The dressing should be changed according to facility policy and based on assessment findings.

Choice B Reason:

Cleaning the insertion site using 20 mL of hydrogen peroxide - Hydrogen peroxide is not recommended for cleaning PICC line insertion sites, as it can cause tissue irritation. The insertion site should be cleaned with an appropriate antiseptic solution per facility guidelines.

Choice C Reason:

Use a 10-mL syringe to flush the line. When completing discharge teaching for a client with a peripherally inserted central catheter (PICC) line, the nurse should include instructions regarding the proper care of the line. Using a 10-mL syringe to flush the line is the appropriate practice to prevent excessive pressure within the catheter and minimize the risk of catheter damage or rupture.

Choice D Reason:

Not elevating the arm above the level of the heart - Elevation of the arm above the heart level is generally not contraindicated for a PICC line. However, it's important to avoid activities that could lead to kinking or pulling on the line. The nurse should provide specific instructions regarding arm movement and care to the client.