A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?
"Your provider will prescribe a different medication regimen."
"This is an expected adverse effect of this medication."
"This finding may indicate possible medication toxicity."
"You will need to increase your fluid intake to resolve this problem."
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale: This choice suggests that the provider will prescribe a different medication regimen. However, this is not necessarily the case. Rifampin is a first-line medication for tuberculosis and its side effects, including the discoloration of body fluids, are well-known and expected. Therefore, it is unlikely that the provider would change the medication regimen solely based on this side effect.
Choice B rationale: This is the correct answer. Rifampin, an antibiotic used to treat tuberculosis, can cause a harmless red-orange discoloration of body fluids, including urine, sweat, tears, and saliva. This is an expected side effect of the medication and does not indicate any harm or toxicity. It is important for the nurse to reassure the client that this is a normal occurrence and does not require any changes to the medication regimen.
Choice C rationale: This choice suggests that the red-orange discoloration of the client’s saliva may indicate possible medication toxicity. However, this is not accurate. While rifampin can have serious side effects, including liver damage and severe gastrointestinal upset, the discoloration of body fluids is not a sign of toxicity. It is a harmless side effect of the medication.
Choice D rationale: This choice suggests that the client will need to increase her fluid intake to resolve the problem. However, increasing fluid intake will not change the discoloration caused by rifampin. The discoloration is a result of the medication itself and is not influenced by the client’s hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A pressure ulcer is a localized injury to the skin and underlying tissue caused by prolonged pressure, shear, friction, or moisture.
Granulation tissue is new connective tissue and blood vessels that form on the surface of a wound during healing . It is usually dark red or pink in color and moist in appearance . Wound tissue that is firm to palpation may indicate edema, inflammation, or infection . Dry brown eschar is dead tissue that covers the wound and prevents healing . Light yellow exudate is a sign of wound infection or necrosis .
Correct Answer is A
Explanation
The nurse should instruct the client to use a 10-mL syringe or larger to flush the PICC line with normal saline or heparin solution, as prescribed, to prevent occlusion and thrombosis. The other options are incorrect because they may cause complications such as infection, phlebitis, or bleeding.
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