A nurse is preparing to administer subcutaneous heparin to a client. Which of the following actions should the nurse take?

A. The client has a negative sputum culture.
When a client with tuberculosis is adhering to the prescribed medication regimen, their sputum cultures should show a decrease in the number of Mycobacterium tuberculosis bacteria. This indicates that the medication is effectively treating the infection. It's important for clients with tuberculosis to complete their full course of treatment to prevent drug-resistant strains of the bacteria from developing.
B. The client tests negative for HIV: This relates to a different infection (HIV) and doesn't necessarily reflect adherence to the tuberculosis medication regimen.
C. The client's liver function test results are within the expected reference range: While liver function tests are important to monitor due to potential medication side effects, they don't directly indicate medication adherence.
D. The client has a positive purified protein derivative (PPD) test: A positive PPD test indicates exposure to the tuberculosis bacteria in the past but does not reflect current adherence to treatment.

A. Instruct the client to increase his fluid intake: While adequate fluid intake is generally important for various reasons, increasing fluid intake would not alter the orange-red discoloration caused by rifampin. This side effect is due to the drug's action on body fluids, not dehydration.
B. Prepare the client for dialysis: Dialysis is not indicated for the harmless orange-red discoloration caused by rifampin. Dialysis is typically used for clients with kidney failure or significant electrolyte imbalances, and it would not address this specific side effect.
C. Document this as an expected finding.
Explanation:
Rifampin, an antibiotic commonly used in the treatment of tuberculosis (TB), can cause a harmless side effect known as "orange-red discoloration." This can affect bodily fluids such as urine, sweat, and tears. This is not a harmful effect and does not indicate a need for any specific intervention. Therefore, the nurse should document this as an expected finding due to the client's use of rifampin.
D. Check the client's liver function test results: The orange-red discoloration is not related to liver function, so checking liver function test results would not provide relevant information about this particular side effect.