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The nurse is preparing the client for discharge.

Exhibits

Which of the following statements indicate the client understands the discharge teaching?

Select the 3 client statements that indicate an understanding of the teaching.

“I can continue my current alcohol intake."

“I can expect my contact lenses to turn red or orange."

“I will need to take my medications for a total of 6 weeks."

“I will need to have a repeat Mantoux test in 4 weeks."

"I am no longer contagious."

“I should notify my provider if I start taking new over-the-counter or prescription medications."

“I will need to have someone observe me when I take medication."

Answer and Explanation

Correct Answer : B,F,G

A. "I can continue my current alcohol intake." The client should avoid alcohol while taking tuberculosis (TB) medications such as isoniazid and rifampin, as alcohol increases the risk of hepatotoxicity.
B. "I can expect my contact lenses to turn red or orange." Rifampin, a common medication used to treat TB, can cause bodily fluids such as urine, sweat, tears, and saliva to turn red or orange. This can stain soft contact lenses permanently, so clients should be informed of this side effect.
C. "I will need to take my medications for a total of 6 weeks." The standard treatment for TB typically lasts at least 6 months, not just 6 weeks. Clients must complete the full course of therapy to prevent drug resistance and recurrence.
D. "I will need to have a repeat Mantoux test in 4 weeks." A Mantoux test (tuberculin skin test) is not needed after a confirmed TB diagnosis with a positive sputum culture. Instead, follow-up evaluations include repeat sputum cultures and chest x-rays.
E. "I am no longer contagious." Clients with active pulmonary TB are considered contagious until they have completed at least two weeks of effective treatment, have improving symptoms, and have three consecutive negative sputum cultures.
F. "I should notify my provider if I start taking new over-the-counter or prescription medications." TB medications, especially rifampin, can interact with many drugs, including oral contraceptives, anticoagulants, and antiretrovirals. Clients must inform their provider of any new medications.
G. "I will need to have someone observe me when I take medication." Directly observed therapy (DOT) is recommended for clients with TB to ensure medication adherence and reduce the risk of treatment failure or drug resistance.

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Correct Answer is A

Explanation

A. Case manager. A case manager assists clients in accessing community resources, including financial assistance programs such as WIC (Women, Infants, and Children) and other social services that provide formula for infants. This referral ensures the client receives the necessary support to meet her baby's nutritional needs.
B. Primary care provider. A primary care provider focuses on the client’s medical care rather than financial or social concerns. While they may provide guidance on infant nutrition, they are not the best resource for addressing the client’s financial difficulties in obtaining formula.
C. Nutritionist. A nutritionist provides dietary guidance but does not handle financial assistance programs. They may educate the client on proper infant feeding, but they cannot directly assist with obtaining formula for a client who cannot afford it.
D. Pediatric nurse practitioner. A pediatric nurse practitioner specializes in infant health but does not typically manage financial concerns. They may assess the baby’s growth and nutritional needs but would refer the client to a case manager or social services for formula assistance.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Options:

Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.

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The nurse is preparing the client for discharge. Exhibits Which of the following statements indicate the client understands the discharge teaching? Select the 3 client statements that indicate an understanding of the teaching.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

Correct Answer is A

Explanation

Exhibits Complete the following sentence by using the list of options The nurse should first address the client’s dropdownfollowed by the client’sdropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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The nurse is preparing the client for discharge.

Exhibits

Which of the following statements indicate the client understands the discharge teaching?

Select the 3 client statements that indicate an understanding of the teaching.