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The nurse is reviewing the client's prescriptions.

Exhibits

The nurse is administering medications to the client and is monitoring potential adverse effects of medications

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.

Body system

Findings

Head, Eyes, Ears, Nose, and Throat (HEENT)

Yellowing of the eyes

Blurred vision

Dry eyes

Gastrointestinal

Abdominal pain

Weight gain

Hematologic

Increased bruising

Increased bleeding tendency

Insomnia

Genitourinary

Darkening of the urine

Urinary frequency

Yellowing of the eyes

Blurred vision

Dry eyes

Abdominal pain

Weight gain

Increased bruising

Increased bleeding tendency

Insomnia

Darkening of the urine

Urinary frequency

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","I"]

Rationale for Correct Options:

Yellowing of the eyes: Indicates hepatotoxicity, a serious adverse effect of isoniazid, rifampin, and pyrazinamide. These drugs can cause liver damage, leading to jaundice, which presents as yellowing of the eyes and skin. Liver function tests should be monitored closely.
Blurred vision: Can result from optic neuritis, a known adverse effect of ethambutol. Ethambutol can damage the optic nerve, causing visual disturbances, including decreased visual acuity and color blindness. Patients should undergo routine eye exams.
Abdominal pain: May indicate hepatotoxicity from TB medications, particularly isoniazid, rifampin, and pyrazinamide. Liver inflammation or damage can manifest as right upper quadrant pain, nausea, and loss of appetite. Monitoring liver enzymes is essential.
Increased bruising: Can result from thrombocytopenia, a hematologic side effect of rifampin. Rifampin can suppress bone marrow function, leading to reduced platelet production, increasing the risk of spontaneous bruising and prolonged bleeding.
Increased bleeding tendency: Suggests liver dysfunction, as the liver is responsible for producing clotting factors. Rifampin-induced hepatotoxicity can impair clotting mechanisms, increasing the risk of excessive bleeding from minor injuries.
Darkening of the urine: A common but harmless side effect of rifampin. Rifampin is excreted in bodily fluids, causing orange or red discoloration of urine, sweat, and tears. Patients should be educated on this expected effect to prevent unnecessary concern.

Rationale for Incorrect Options:

Dry eyes: Not associated with TB medications and may be due to environmental factors or dehydration.
Weight gain: Unlikely with TB treatment, as these medications typically cause weight loss rather than weight gain.
Insomnia: Not a significant adverse effect of first-line TB drugs and may be related to the client’s illness or other factors.
Urinary frequency: Not a common reaction to TB medications, as these drugs do not significantly affect renal function or bladder activity.

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Correct Answer is A

Explanation

A. The client reports pain is reduced when he is positioned on his side. This information is relevant to the client's current condition and care plan. Pain management is a critical aspect of nursing care, and informing the oncoming nurse about the client’s preferred position for pain relief ensures continuity of care and appropriate interventions.
B. The client's partner visited earlier today for 2 hours. While social interactions are important for the client’s well-being, this information is not essential for a shift report unless it directly affects the client's condition or care needs.
C. The client's mother died 4 years ago from breast cancer. While family history can be relevant for long-term medical planning, it is not pertinent to the immediate shift report, which should focus on the client's current status and care needs.
D. The client received the prescribed antibiotic every 8 hours. While medication administration is important, the oncoming nurse can verify this information in the medication administration record (MAR). Shift reports typically focus on changes in condition, ongoing concerns, and necessary interventions rather than routine medication schedules.

A. "Droplet precautions require that I wear a gown and gloves when providing client care." B. "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20," C. "Soiled dressings should be placed in a biohazard trash receptacle." D. "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub."

Correct Answer is C

Explanation

A. "Droplet precautions require that I wear a gown and gloves when providing client care." Droplet precautions require wearing a surgical mask when within three feet of the client, but gowns and gloves are only needed if direct contact with secretions is expected. Incorrect PPE use can lead to inadequate protection or unnecessary resource use. Understanding specific precaution types ensures proper infection control.
B. "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20." Blood spills should be cleaned using a 1:10 bleach solution, not 1:20, to ensure effective decontamination. A stronger bleach concentration eliminates bloodborne pathogens like HIV and hepatitis B. The solution should be applied to the spill and left to sit before wiping. Using an incorrect dilution reduces disinfection effectiveness.
C. "Soiled dressings should be placed in a biohazard trash receptacle." Soiled dressings contain bodily fluids and potential pathogens, so they must be disposed of in a biohazard waste container. Regular trash does not provide adequate containment and increases the risk of contamination. Proper disposal protects healthcare workers and the environment from infection. Adhering to these protocols ensures compliance with infection control standards.
D. "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub." Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores, requiring handwashing with soap and water. The mechanical action of scrubbing is necessary to remove spores from the hands. Proper hand hygiene reduces transmission risks in healthcare settings. Infection control protocols emphasize soap and water for C. difficile prevention.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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