A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?

Red-orange discoloration of urine

Increased ecchymosis

Yellow appearance of the sclerae

Lack of energy

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct finding, because rifampin is an antibiotic that can cause red-orange discoloration of urine, saliva, sweat, tears, and other body fluids. This is a harmless and expected adverse effect of rifampin, and does not indicate any damage to the kidneys or liver. The client should be informed about this effect and advised to wear soft contact lenses, as rifampin can stain them permanently.

Choice B reason: This is an incorrect finding, because increased ecchymosis, or bruising, is not a harmless or expected adverse effect of rifampin, but a sign of bleeding disorder or thrombocytopenia, which is a rare but serious complication of rifampin. Rifampin can interfere with the synthesis of vitamin K, which is essential for blood clotting, and cause bleeding problems. The client should report any signs of bleeding, such as ecchymosis, petechiae, hematuria, or epistaxis, to the provider.

Choice C reason: This is an incorrect finding, because yellow appearance of the sclerae, or jaundice, is not a harmless or expected adverse effect of rifampin, but a sign of liver damage or hepatitis, which is a rare but serious complication of rifampin. Rifampin can cause inflammation and injury to the liver cells, and impair the metabolism and excretion of bilirubin, which is a yellow pigment that accumulates in the skin and eyes when the liver is damaged. The client should report any signs of liver dysfunction, such as jaundice, dark urine, pale stools, or abdominal pain, to the provider.

Choice D reason: This is an incorrect finding, because lack of energy, or fatigue, is not a harmless or expected adverse effect of rifampin, but a sign of anemia or hypothyroidism, which are rare but serious complications of rifampin. Rifampin can cause hemolytic anemia, which is a condition that occurs when the red blood cells are destroyed faster than they are produced, and hypothyroidism, which is a condition that occurs when the thyroid gland produces insufficient thyroid hormone. The client should report any signs of anemia or hypothyroidism, such as fatigue, weakness, pallor, or cold intolerance, to the provider.

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Correct Answer is D

Explanation

Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.

Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.

Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.

Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.

A. Place compression stockings on the lower extremities. B. Apply cold compresses to the affected extremity. C. Gently massage the area every 4 hr. D. Inform the client that heparin is prescribed to dissolve the thrombus.

Correct Answer is A

Explanation

Choice A reason: This is the best action, because compression stockings can help improve the blood flow and prevent the formation of new clots in the veins of the legs. Compression stockings can also reduce the swelling, pain, and inflammation caused by thrombophlebitis.

Choice B reason: This is an incorrect action, because cold compresses can cause vasoconstriction and worsen the blood flow and the clotting process in the affected vein. Cold compresses can also increase the discomfort and numbness of the extremity.

Choice C reason: This is an incorrect and dangerous action, because gently massaging the area can dislodge the clot and cause it to travel to the lungs, heart, or brain, resulting in a life-threatening complication, such as pulmonary embolism, myocardial infarction, or stroke.

Choice D reason: This is an incorrect and misleading statement, because heparin is not prescribed to dissolve the thrombus, but to prevent the growth and extension of the existing clot and the formation of new clots. Heparin is an anticoagulant that inhibits the clotting factors in the blood, but does not break down the clot. The body's own enzymes, such as plasmin, are responsible for dissolving the clot.

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A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?

Nursing Test Bank

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