A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?

A client who has multiple sclerosis and reports ataxia and vertigo

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%

A client who has left-sided paralysis and slurred speech from a prior stroke

A client who has thrombocytopenia and reports a nosebleed

Answer and Explanation

The Correct Answer is D

The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.

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Correct Answer is A

Explanation

Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.

A. "Your provider will prescribe a different medication regimen." B. "This is an expected adverse effect of this medication." C. "This finding may indicate possible medication toxicity." D. "You will need to increase your fluid intake to resolve this problem."

Correct Answer is B

Explanation

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.

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A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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