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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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "Document the infiltration." While documentation is necessary, it is not the first action the nurse should take. Immediate intervention is required to prevent further complications from IV infiltration, such as tissue damage or fluid leakage into surrounding tissues.
B. "Stop the infusion." The first action the nurse should take is to stop the IV infusion to prevent further infiltration of fluid into the surrounding tissues. Continuing the infusion could worsen swelling, discomfort, and potential tissue injury.
C. "Elevate the arm." Elevating the affected extremity can help reduce swelling by promoting fluid reabsorption, but this should be done after stopping the infusion to prevent additional fluid from accumulating in the tissues.
D. "Apply a warm compress." A warm compress can help promote absorption of non-vesicant solutions, while a cold compress is preferred for certain medications to reduce swelling and pain. However, applying a compress should only be done after stopping the infusion and assessing the severity of infiltration.

A. Clear rhinorrhea B. Medications for a cardiac anomaly C. Chemotherapy treatments D. Two diarrhea stools in the last day

Correct Answer is C

Explanation

A. Clear rhinorrhea. Mild respiratory illnesses, such as a common cold with clear nasal discharge, do not contraindicate varicella vaccination. The immunization can still be administered unless the child has a moderate to severe illness with fever.
B. Medications for a cardiac anomaly. Having a congenital heart defect or taking cardiac medications does not typically contraindicate varicella vaccination. However, children on high-dose immunosuppressive therapy for heart conditions may need further evaluation before receiving live vaccines.
C. Chemotherapy treatments. Chemotherapy suppresses the immune system, increasing the risk of severe complications from live vaccines like varicella. Children undergoing chemotherapy should not receive live-virus vaccines until immune function has sufficiently recovered, as determined by a healthcare provider.
D. Two diarrhea stools in the last day. Mild, self-limiting diarrhea does not contraindicate vaccination. Only children with severe acute gastrointestinal illness should have vaccinations postponed until they recover.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Correct Answer is C

Explanation

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