A nurse is caring for a client who is taking rifampin. Which of the following findings should the nurse monitor for as an adverse effect of the medication?

Blurred vision

Jaundice

Irregular heart rate

Constipation

Answer and Explanation

The Correct Answer is B

A. Blurred vision can be a side effect of many medications, but it is not a common adverse effect specifically associated with rifampin. Rifampin’s side effects are more commonly related to liver function and gastrointestinal issues.
B. Jaundice is a significant adverse effect of rifampin, indicating potential liver damage. Rifampin can cause hepatotoxicity, leading to elevated liver enzymes and bilirubin levels, which manifest as jaundice. Monitoring liver function tests is crucial for clients on rifampin to detect any early signs of liver damage.
C. Irregular heart rate is not typically associated with rifampin. While rifampin can interact with other medications that affect heart rate, it does not directly cause arrhythmias.
D. Constipation is not a common adverse effect of rifampin. Gastrointestinal side effects of rifampin usually include nausea, vomiting, and diarrhea rather than constipation.

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Correct Answer is C

Explanation

A. A child who recently received the human papillomavirus vaccine. This is not a contraindication for receiving the varicella vaccine. Vaccines can generally be administered simultaneously or at any interval between doses of different vaccines.
B. A young adult who has an allergy to eggs. This is not a contraindication for the varicella vaccine. The varicella vaccine does not contain egg proteins, so an egg allergy does not prevent someone from receiving it.
C. A client who has AIDS. This is a contraindication for the varicella vaccine. Individuals with severe immunocompromising conditions, such as AIDS, should not receive live vaccines like the varicella vaccine due to the risk of severe vaccine-related complications.
D. An older adult client living in a long-term care facility. This is not a contraindication for the varicella vaccine. Older adults can receive the varicella vaccine unless they have specific contraindications such as severe immunocompromise.

A. Use the Z-track method to administer the medication. B. Grasp skin between thumb and forefinger throughout the injection. C. Gently massage the site following the injection. D. Aspirate the syringe prior to injecting the heparin.

Correct Answer is B

Explanation

A. Use the Z-track method to administer the medication is typically used for intramuscular injections to prevent medication from leaking back into the subcutaneous tissue. It is not appropriate for subcutaneous heparin injections and does not help minimize bleeding.
B. Grasp skin between thumb and forefinger throughout the injection helps to stabilize the tissue and ensure the medication is delivered into the subcutaneous layer. This technique can help minimize bleeding and bruising by reducing tissue trauma during the injection.
C. Gently massage the site following the injection is not recommended for heparin injections as it can increase the risk of bleeding and bruising. Massaging the site can cause the medication to spread into the surrounding tissue, leading to hematoma formation.
D. Aspirate the syringe prior to injecting the heparin is not necessary for subcutaneous injections and can increase the risk of bleeding. Aspiration is typically done for intramuscular injections to ensure the needle is not in a blood vessel, but it is not required for subcutaneous heparin administration.

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A nurse is caring for a client who is taking rifampin. Which of the following findings should the nurse monitor for as an adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer the varicella vaccine to a group of clients. The nurse should identify which of the following clients as having a contraindication for receiving this immunization?

Correct Answer is C

Explanation

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take to minimize bleeding following the injection?

Correct Answer is B

Explanation

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