A nurse observes orange discoloration of urine in a patient taking rifampin. What is the appropriate response?

Correct Answer: B

Rationale: The correct response to the scenario of observing orange discoloration of urine in a patient taking rifampin is option B) Reassure the patient that this is normal. Rifampin is known to cause harmless discoloration of bodily fluids, including urine, sweat, saliva, and tears, turning them orange. It is important for a nurse to educate the patient about this common side effect to alleviate concerns and ensure medication compliance. Option A) Notify the healthcare provider immediately is incorrect because orange discoloration of urine due to rifampin is a well-known and harmless side effect that does not require immediate medical intervention. Option C) Check for additional signs of hepatotoxicity is incorrect as orange discoloration of urine in this context is not indicative of hepatotoxicity. Rifampin-induced hepatotoxicity typically presents with symptoms such as jaundice, elevated liver enzymes, and abdominal pain. Option D) Discontinue the medication is an extreme response as rifampin is a crucial medication for treating tuberculosis and other infections. Discontinuing it based solely on harmless discoloration of urine would not be appropriate and could compromise the patient's treatment. In an educational context, understanding common side effects of medications like rifampin is essential for nurses to provide comprehensive patient care. Educating patients about expected side effects can improve adherence to treatment regimens and alleviate unnecessary anxiety or concern. Nurses play a vital role in medication education and management, ensuring safe and effective patient care.

Correct Answer: B

Rationale: Rationale: The correct answer is B) There is an air leak in the system. Continuous bubbling in the water-seal chamber of a chest tube indicates an air leak in the system. This can lead to ineffective lung re-expansion as the negative pressure required for proper drainage is compromised. Addressing the air leak promptly is crucial to prevent complications such as pneumothorax. Option A) The chest tube is functioning properly is incorrect because continuous bubbling indicates an issue in the system, not proper function. Option C) Suction pressure is too high is incorrect as high suction pressure would typically lead to excessive bubbling, not continuous bubbling. Option D) The patient has a pneumothorax is incorrect as continuous bubbling in the water-seal chamber does not directly indicate a pneumothorax but rather an air leak in the system. Understanding chest tube management is essential for nurses caring for patients with respiratory issues. Recognizing and addressing complications promptly is crucial for patient safety and optimal outcomes.

Correct Answer: C

Rationale: In this NCLEX Oxygenation practice question, the correct answer is C) The patient puffs cheeks while exhaling. This finding indicates a need for further teaching about pursed-lip breathing in a COPD patient because puffing the cheeks while exhaling is not a correct technique for pursed-lip breathing. Pursed-lip breathing involves inhaling through the nose slowly and deeply, then exhaling through pursed lips for a longer period than inhaling. This technique helps to keep airways open and prevent alveoli collapse in COPD patients. Option A is incorrect because inhaling deeply through the nose is a component of pursed-lip breathing. Option B is incorrect because exhaling twice as long as inhaling is also a key aspect of pursed-lip breathing. Option D is incorrect because practicing breathing while sitting upright is a suitable position for performing pursed-lip breathing exercises. Educationally, understanding the correct technique for pursed-lip breathing is crucial in managing COPD patients' respiratory distress. By identifying incorrect practices, healthcare professionals can intervene and provide proper education to ensure optimal patient outcomes. It is essential for nurses to educate patients on correct breathing techniques to improve oxygenation and decrease the work of breathing in COPD.

Correct Answer: C

Rationale: The correct answer is C) "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." This action is most effective in improving compliance with discharge teaching for a patient with COPD. Taking Tylenol for chest wall pain indicates that the patient is managing their discomfort, which can be a common symptom of COPD exacerbation. By addressing the pain, the patient is more likely to engage in activities and breathing exercises that are crucial for improving lung function and overall health. This response demonstrates the patient's understanding of self-care and symptom management, essential components of COPD management. Options A, B, and D all mention increased albuterol inhaler use, which may indicate worsening symptoms. While it is important for the nurse to address this, the primary focus should be on managing chest wall pain as it can impact the patient's ability to participate in necessary self-care activities and hinder compliance with discharge instructions. In an educational context, this question highlights the importance of holistic care for patients with COPD. It emphasizes the need to address not only respiratory symptoms but also pain management to improve patient outcomes and adherence to treatment plans. Understanding the rationale behind the correct answer reinforces the significance of comprehensive assessment and individualized care in nursing practice.

Correct Answer: C

Rationale: In this scenario, the correct intervention for a patient experiencing nausea and vomiting post-surgery is to apply a cold compress (Option C). This intervention helps to alleviate symptoms by providing comfort and reducing nausea through the application of cold to the forehead or back of the neck. Providing antiemetic medications (Option A) may be necessary in some cases, but addressing the discomfort and cooling effect of a cold compress should be the initial priority. Offering oral hydration (Option B) is important, but addressing the nausea and vomiting with a cold compress takes precedence. Encouraging deep breathing exercises (Option D) is beneficial for respiratory function but does not directly address the immediate symptoms of nausea and vomiting. Educationally, understanding the rationale behind prioritizing interventions based on immediate patient needs is crucial for nursing practice. It teaches students to prioritize care based on assessment findings and to address the most pressing issues first to ensure patient comfort and well-being. It also highlights the importance of quick thinking and appropriate intervention selection in emergency situations.