An adult exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
Conversion of the client's PPD test from negative to positive
History of intravenous drug abuse
Current diagnosis of hepatitis B
Length of time of the exposure to tuberculosis
The Correct Answer is C
Choice A: Conversion of the client's PPD test from negative to positive is not the most important information for the nurse to note, as this is an expected finding for a client who has been exposed to tuberculosis and does not affect the administration of isoniazid. This is a distractor choice.
Choice B: History of intravenous drug abuse is not the most important information for the nurse to note, as this is not directly related to the use of isoniazid and does not contraindicate its administration. This is another distractor choice.
Choice C: Current diagnosis of hepatitis B is the most important information for the nurse to note, as this can increase the risk of hepatotoxicity and liver damage from isoniazid, which requires close monitoring and possible dose adjustment. Therefore, this is the correct choice.
Choice D: Length of time of the exposure to tuberculosis is not the most important information for the nurse to note, as this does not influence the dosage or frequency of isoniazid and does not indicate any complication or adverse reaction. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Securing chest tube to the stretcher for transport is a good practice, but it is not the most important action. The chest tube should be secured to prevent accidental dislodgement or kinking, but it does not affect the function of the chest tube or the drainage system.
Choice B: Administering PRN pain medication prior to transport is a compassionate action, but it is not the most important action. The client may experience pain due to the chest tube, the intubation, or the underlying condition, but pain relief is not a priority over maintaining adequate ventilation and drainage.
Choice C: Marking the amount of chest drainage on the container is a useful action, but it is not the most important action. The amount of chest drainage should be recorded and reported to monitor the client's status and detect any complications, such as hemorrhage or infection, but it does not affect the immediate function of the chest tube or the drainage system.
Choice D: Keeping the chest tube container below the site of insertion is the most important action for the nurse to take. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.
Correct Answer is D
Explanation
Choice A: Mark an outline of the 'olive-shaped' mass in the right epigastric area. This is not a priority action, as it does not address the immediate needs of the infant. The 'olive-shaped' mass is a sign of pyloric stenosis, but it does not affect the infant's hydration or nutrition.
Choice B: Instruct parents regarding care of the incisional area. This is an important action, but not a priority before surgery. The parents need to know how to care for the incisional area after surgery, but this can be done later.
Choice C: Monitor amount of intake and infant's response to feedings. This is a relevant action, but not a priority before surgery. The infant with pyloric stenosis may have vomiting, dehydration, and electrolyte imbalance due to gastric outlet obstruction. Monitoring intake and output can help assess the severity of these problems, but it does not correct them.
Choice D: Initiate a continuous infusion of IV fluids per prescription. This is the priority action before surgery, as it can prevent or treat dehydration and electrolyte imbalance in the infant. IV fluids can also help maintain blood volume and perfusion during surgery.
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