A client with tuberculosis is prescribed rifampin. What is the most important teaching point for the nurse to emphasize?

Correct Answer: C

Rationale: The correct answer is C) Do not stop the medication even if symptoms improve. This is the most important teaching point for the nurse to emphasize because rifampin is an antibiotic used to treat tuberculosis, which is a serious infectious disease. It is crucial for the client to complete the full course of treatment to ensure that all the TB bacteria are killed and to prevent the development of drug-resistant strains. Option A) Avoid direct sunlight to prevent photosensitivity is incorrect because rifampin does not typically cause photosensitivity. Option B) Expect orange discoloration of urine and tears is a common side effect of rifampin due to its color, but it is not as important as ensuring completion of the medication. Option D) Avoid foods high in potassium is unrelated to rifampin therapy and is not a significant teaching point for this medication. In an educational context, it is essential for nurses to understand the rationale behind medication teaching to provide comprehensive care to their clients. By emphasizing the importance of completing the full course of rifampin therapy, nurses can help ensure treatment success and prevent the spread of tuberculosis. This teaching point highlights the critical role of patient education in promoting adherence to treatment regimens and improving health outcomes.

Correct Answer: B

Rationale: In this question, the correct answer is option B) Oxygen saturation improved to 94%. This finding indicates improvement in a client with COPD who is being treated with a bronchodilator. The rationale behind this is that in COPD, impaired gas exchange is a common problem due to airway obstruction and decreased lung function. By improving oxygen saturation, the bronchodilator is effectively helping the client to oxygenate better, which is a critical goal in managing COPD. Option A) Heart rate increased to 100 beats per minute is incorrect because an increased heart rate may indicate tachycardia, which could be a sign of distress or inadequate response to the medication. Option C) Client reports mild dizziness is incorrect as dizziness is not a typical sign of improvement in COPD with bronchodilator therapy. Option D) Respiratory rate increased to 24 breaths per minute is incorrect because an increased respiratory rate may suggest respiratory distress rather than improvement in oxygenation status. Educationally, understanding the expected outcomes of bronchodilator therapy in COPD is crucial for nurses caring for these patients. Monitoring oxygen saturation levels is a key assessment parameter to evaluate the effectiveness of treatment and ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, option C, "Disconnection of the chest tube from the drainage system," requires immediate action. This is because a disconnected chest tube can lead to air entering the pleural space, causing a pneumothorax or a collapsed lung, which is a life-threatening emergency. Immediate intervention is crucial to prevent complications and ensure the client's safety and well-being. Option A, "Drainage of 75 mL in the past hour," is within the expected range for a chest tube output and does not require immediate action. It is important to monitor drainage, but this amount alone does not indicate a critical issue. Option B, "Absence of bubbling in the water seal chamber," indicates that the system is intact and functioning correctly, which is a normal finding. Absence of bubbling can be an expected observation in certain phases of chest tube management and does not warrant immediate action. Option D, "Fluctuation in the water seal chamber with respiration," is a normal finding indicating proper functioning of the chest tube system. Fluctuation with respiration indicates that the system is maintaining appropriate pressure differentials and is not a cause for concern. In an educational context, understanding the significance of each observation in the management of a client with a chest tube is essential for providing safe and effective care. Nurses must be able to differentiate between normal and abnormal findings to intervene promptly and prevent complications in clients with chest tubes. This question highlights the critical thinking skills required in assessing and managing clients with complex respiratory conditions, such as those needing chest tube management.

Correct Answer: B

Rationale: In the context of managing asthma with inhaled corticosteroids, option B, "Rinse your mouth after each use of the inhaler," is the correct teaching point that the nurse should emphasize. This is because inhaled corticosteroids can lead to oral thrush or fungal infections in the mouth due to their local effects on mucous membranes. Rinsing the mouth after each use helps to minimize this risk and maintain oral health. Option A, "Use the corticosteroid only during an asthma attack," is incorrect because inhaled corticosteroids are typically used on a daily basis as maintenance therapy to reduce airway inflammation and prevent asthma attacks. Using them only during an attack would not provide the intended long-term benefits. Option C, "Shake the inhaler and exhale quickly before using," is incorrect as shaking the inhaler is typically necessary for metered-dose inhalers (MDIs) but not specifically for inhaled corticosteroids. Exhaling quickly before using the inhaler is also not a standard instruction for inhaled corticosteroids. Option D, "Use the corticosteroid before the bronchodilator," is incorrect because inhaled corticosteroids are usually recommended to be used before bronchodilators to allow for better penetration of the corticosteroid into the airways and optimize their effectiveness in reducing inflammation. In an educational context, emphasizing the importance of rinsing the mouth after using inhaled corticosteroids helps to prevent potential side effects and complications, promoting adherence to the prescribed treatment regimen and overall better outcomes in managing asthma. It is crucial for nurses to provide clear and accurate teaching points to empower patients in self-management and promote their understanding of asthma therapy.

Correct Answer: A

Rationale: The correct answer is A) Take a deep breath and hold it for 10 seconds. After using a rescue inhaler for asthma, it is important for the client to hold their breath for about 10 seconds to allow the medication to reach deep into the lungs for optimal effectiveness. This technique ensures that the medication is delivered to where it is needed most to help alleviate asthma symptoms quickly. Option B) Exhale quickly to clear the lungs is incorrect because exhaling quickly after using the inhaler can actually expel the medication before it has a chance to work effectively. This can lead to reduced therapeutic effects of the medication and may not provide the desired relief for the client's asthma symptoms. Option C) Rinse their mouth with water is incorrect as it is a recommended step after using corticosteroid inhalers, not rescue inhalers. Rescue inhalers typically contain bronchodilators and rinsing the mouth is not necessary after their use. Option D) Take another puff immediately without waiting is incorrect because it is essential to follow the prescribed dosing instructions for the rescue inhaler. Taking another puff immediately without waiting can lead to an overdose of medication and may cause adverse effects on the client's health. Educationally, understanding the proper technique for using a rescue inhaler is crucial for clients with asthma to effectively manage their condition. Teaching clients the correct steps ensures they receive the maximum benefit from their medication and can better control their asthma symptoms. It is important for healthcare providers to provide clear and accurate instructions to clients to promote proper self-management of their asthma.