A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?

Correct Answer: D

Rationale: Step 1: Isoniazid (INH) can cause liver toxicity. Step 2: Regular liver function tests help monitor for liver damage. Step 3: Monitoring liver function is crucial to prevent serious complications. Step 4: Other choices are not directly related to INH's side effects. Summary: Choice D is correct as it directly addresses a potential serious side effect of INH. Choices A, B, and C are not directly relevant to the medication's side effects.

Correct Answer: B

Rationale: The correct action is to check the client's blood pressure first. A sudden onset of pounding headache and blurred vision in a client with a spinal cord injury at T6 can indicate autonomic dysreflexia. Checking the blood pressure is crucial as autonomic dysreflexia can lead to severe hypertension, which can result in life-threatening complications such as stroke or seizure. Immediate assessment and intervention are necessary to prevent further harm. Administering pain medication without addressing the underlying cause can exacerbate hypertension. Placing the client in a supine position can worsen symptoms, and increasing fluid intake does not address the immediate issue at hand. Therefore, checking the blood pressure is the priority to identify and manage autonomic dysreflexia effectively.

Correct Answer: D

Rationale: The correct answer is D: Crackles in the lungs. Left-sided heart failure leads to fluid accumulation in the lungs, causing crackles on auscultation. This indicates pulmonary congestion. Peripheral edema (A) is more common in right-sided heart failure. Jugular vein distention (B) is typically seen in right-sided heart failure due to increased venous pressure. Hepatomegaly (C) is more common in conditions like liver disease, not specifically left-sided heart failure.

Correct Answer: C

Rationale: The correct answer is C because using cotton balls to cushion the oxygen tubing on the ears helps prevent skin irritation or pressure ulcers. This indicates the client understands the importance of skin care and comfort while using oxygen therapy. A: Incorrect. The client should wear oxygen during all activities that increase oxygen demand, not just when feeling short of breath during exercise. B: Incorrect. Using portable oxygen near an open flame like a grill can result in a fire hazard. D: Incorrect. Smoking while using oxygen therapy is extremely dangerous and can lead to a fire.

Correct Answer: D

Rationale: The correct answer is D: Keep padded clamps at the bedside for use if the drainage system is interrupted. This is essential because if the drainage system is interrupted, the nurse needs to immediately clamp the tube to prevent air from entering the pleural space. Clamping the tube can prevent a potentially life-threatening situation. A: Never strip the tubing to maintain patency - Stripping the tubing can lead to increased negative pressure, which can be harmful. B: Secure tubing junctions with tape to prevent accidental disconnections - While securing tubing is important, clamping the tube in case of interruption is more critical. C: Set wall suction at the level recommended by the device manufacturer - This is important for proper functioning but not as crucial as having clamps ready for emergencies.