Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis.
Which of the following statements should the nurse include in the teaching?
A. "Lifelong treatment with this medication is necessary.”.
Tuberculosis treatment with rifampin typically lasts 6 to 9 months. Lifelong therapy is not required for TB, and unnecessary prolonged use increases the risk of drug resistance and hepatotoxicity.
B. "The medication causes amenorrhea if taken along with an oral contraceptive.”.
Rifampin induces liver enzymes that accelerate the metabolism of oral contraceptives, making them less effective. It does not cause amenorrhea, but it necessitates the use of non-hormonal backup contraception.
C. "You should wear glasses instead of contacts while taking this medication.”.
Rifampin causes a harmless reddish-orange discoloration of urine, sweat, tears, and saliva. This can permanently stain soft contact lenses, so clients are advised to wear eyeglasses during the treatment course.
D. "A yellow tint to the skin is an expected reaction to the medication.”.
A yellow tint to the skin or sclera indicates jaundice, which is a sign of hepatotoxicity. This is a serious adverse effect rather than an expected reaction and must be reported immediately.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Fall NS 126 Proctored Exam 1. Take the full exam now
Full Explanation
Choice A rationale: Tuberculosis treatment with rifampin typically lasts 6 to 9 months. Lifelong therapy is not required for TB, and unnecessary prolonged use increases the risk of drug resistance and hepatotoxicity.
Choice B rationale: Rifampin induces liver enzymes that accelerate the metabolism of oral contraceptives, making them less effective. It does not cause amenorrhea, but it necessitates the use of non-hormonal backup contraception.
Choice C rationale: Rifampin causes a harmless reddish-orange discoloration of urine, sweat, tears, and saliva. This can permanently stain soft contact lenses, so clients are advised to wear eyeglasses during the treatment course.
Choice D rationale: A yellow tint to the skin or sclera indicates jaundice, which is a sign of hepatotoxicity. This is a serious adverse effect rather than an expected reaction and must be reported immediately.
Similar Questions
A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide.
The nurse should identify that the client needs which of the following tests while taking this medication therapy?
A. Liver function tests.
The nurse should identify that the client needs liver function tests while taking pyrazinamide. Pyrazinamide is one of the drugs used to treat tuberculosis, and it is known to potentially cause hepatotoxicity (liver damage). Regular monitoring of liver function tests, including liver enzymes like ALT and AST, is essential to detect any liver-related issues early and ensure the client's safety during the medication therapy.
B. Thyroid function studies.
Thyroid function studies are not typically necessary while a client is taking pyrazinamide. Pyrazinamide is not known to have a direct effect on thyroid function.
C. Blood glucose levels.
Blood glucose levels do not need to be monitored specifically due to pyrazinamide therapy. Although some antituberculosis drugs may affect blood sugar levels, pyrazinamide is not a common culprit for such side effects.
D. Gallbladder studies.
Gallbladder studies are not typically indicated while taking pyrazinamide. Pyrazinamide is not known to cause specific issues related to the gallbladder. Monitoring liver function is more critical due to its potential hepatotoxicity.
Full Explanation
Choice A rationale:
The nurse should identify that the client needs liver function tests while taking pyrazinamide. Pyrazinamide is one of the drugs used to treat tuberculosis, and it is known to potentially cause hepatotoxicity (liver damage). Regular monitoring of liver function tests, including liver enzymes like ALT and AST, is essential to detect any liver-related issues early and ensure the client's safety during the medication therapy.
Choice B rationale:
Thyroid function studies are not typically necessary while a client is taking pyrazinamide. Pyrazinamide is not known to have a direct effect on thyroid function.
Choice C rationale:
Blood glucose levels do not need to be monitored specifically due to pyrazinamide therapy. Although some antituberculosis drugs may affect blood sugar levels, pyrazinamide is not a common culprit for such side effects.
Choice D rationale:
Gallbladder studies are not typically indicated while taking pyrazinamide. Pyrazinamide is not known to cause specific issues related to the gallbladder. Monitoring liver function is more critical due to its potential hepatotoxicity.
A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?
A. Urine output 200 mL/4 hr.
The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.
B. Heart rate 104/min.
A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.
C. Peripheral pulses +1.
Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.
D. Urine specific gravity 1.04. .
A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .
Full Explanation
Choice A rationale:
The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.
Choice B rationale:
A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.
Choice C rationale:
Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.
Choice D rationale:
A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .
A nurse is reinforcing teaching about a heart-healthy diet with a group of clients who have hypertension.
Which of the following statements by the clients indicates a need for further teaching?
A. "Fresh fruits are good to include with meals.”.
"Fresh fruits are good to include with meals.”. Including fresh fruits with meals is an excellent choice for a heart-healthy diet. Fresh fruits are rich in essential vitamins, minerals, and fiber, which can help lower blood pressure and reduce the risk of heart disease.
B. "I will replace table salt with dried herbs.”.
"I will replace table salt with dried herbs.”. This is a good choice for reducing sodium intake. Dried herbs can add flavor to food without the need for table salt, which is high in sodium. Lowering sodium intake is crucial for individuals with hypertension to manage their condition and maintain a heart-healthy diet.
C. "I can have a cola drink twice a day.”.
"I can have a cola drink twice a day.”. This choice is incorrect. Consuming cola drinks, which are high in sugar and caffeine, is not advisable for individuals with hypertension. High sugar intake can contribute to weight gain and high blood pressure, while caffeine can temporarily raise blood pressure. Clients with hypertension should limit or avoid soda consumption.
D. "I can eat frozen juice bars for a snack.”.
"I can eat frozen juice bars for a snack.”. Frozen juice bars can be a healthier alternative to high-calorie, sugary snacks. However, the specific content of these bars should be considered. If they contain added sugars or high levels of sodium, it may not be the best choice. Clients with hypertension should focus on snacks that are low in added sugars and salt.
Full Explanation
Choice A rationale:
"Fresh fruits are good to include with meals.”. Including fresh fruits with meals is an excellent choice for a heart-healthy diet. Fresh fruits are rich in essential vitamins, minerals, and fiber, which can help lower blood pressure and reduce the risk of heart disease.
Choice B rationale:
"I will replace table salt with dried herbs.”. This is a good choice for reducing sodium intake. Dried herbs can add flavor to food without the need for table salt, which is high in sodium. Lowering sodium intake is crucial for individuals with hypertension to manage their condition and maintain a heart-healthy diet.
Choice C rationale:
"I can have a cola drink twice a day.”. This choice is incorrect. Consuming cola drinks, which are high in sugar and caffeine, is not advisable for individuals with hypertension. High sugar intake can contribute to weight gain and high blood pressure, while caffeine can temporarily raise blood pressure. Clients with hypertension should limit or avoid soda consumption.
Choice D rationale:
"I can eat frozen juice bars for a snack.”. Frozen juice bars can be a healthier alternative to high-calorie, sugary snacks. However, the specific content of these bars should be considered. If they contain added sugars or high levels of sodium, it may not be the best choice. Clients with hypertension should focus on snacks that are low in added sugars and salt.