A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin.
Which of the following outcomes indicates that the client is adhering to the medication regimen?

The client tests negative for HIV.

The client has a negative sputum culture.

The client’s liver function test results are within the expected reference range.

The client has a positive purified protein derivative test.

Answer and Explanation

The Correct Answer is B

The client has a negative sputum culture. This indicates that the client is adhering to the medication regimen because a negative sputum culture means that the client is no longer infectious and has cleared the tuberculosis bacteria from their lungs.

Choice A is wrong because testing negative for HIV does not indicate that the client is adhering to the medication regimen for tuberculosis. HIV testing is not related to tuberculosis treatment.

Choice C is wrong because having a positive purified protein derivative test does not indicate that the client is adhering to the medication regimen for tuberculosis.

A positive PPD test means that the client has been exposed to tuberculosis, but it does not indicate whether the client has an active or latent infection. Choice D is wrong because having liver function test results within the expected reference range does not indicate that the client is adhering to the medication regimen for tuberculosis.

Liver function tests are used to monitor for possible adverse effects of isoniazid and rifampin, which can cause hepatotoxicity, but they do not reflect the effectiveness of the treatment.

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Correct Answer is C

Explanation

Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.

Choice Ais wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.

Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.

Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.

Choice Dis wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.

A. Expel the air bubble from the syringe prior to injection. B. Apply firm pressure to the injection site following administration. C. Insert the syringe needle halfway into the client’s skin. D. Administer the medication into the client’s muscles.

Correct Answer is B

Explanation

Choice A rationale:

The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.

Choice B rationale:

After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.

Choice C rationale:

The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.

Choice D rationale:

Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.

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A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of the following outcomes indicates that the client is adhering to the medication regimen?

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A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin.
Which of the following outcomes indicates that the client is adhering to the medication regimen?