A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness?

Correct Answer: A

Rationale: Rifampin (Rifadin) is a medication used to treat tuberculosis, and it is known to cause orange discoloration of bodily fluids, including urine and tears. Option A is the correct response because it addresses a potential side effect related to vision changes, particularly red-green color discrimination, which can occur with rifampin use. By asking about visual changes, the nurse can assess for a less common but serious side effect of the medication. Options B and D are incorrect because they do not address the specific side effect of orange discoloration associated with rifampin. Option C is also incorrect because it inaccurately states that the discoloration is normal. Providing this misinformation could lead to patient confusion or unnecessary concern. In an educational context, understanding the side effects of medications is crucial for nurses to provide safe and effective care. By knowing the expected side effects of rifampin, nurses can educate patients on what to expect and monitor for any potential complications. This question highlights the importance of thorough medication education and assessment to ensure patient safety and understanding.

Correct Answer: A

Rationale: In this scenario, the priority intervention for a patient who has just had a coronary artery bypass graft (CABG) is to monitor cardiac output (Option A). This is the correct answer because after CABG surgery, ensuring adequate cardiac output is crucial for the patient's overall hemodynamic stability and recovery. By closely monitoring cardiac output, the nurse can assess the heart's ability to pump effectively and detect any signs of decreased perfusion or cardiac complications early on. Option B, administering intravenous fluids, is not the priority intervention in this case because blindly giving fluids without assessing the patient's cardiac function can potentially worsen the patient's condition, especially if there are underlying cardiac issues. Option C, monitoring the patient's INR level, is not the priority immediately after CABG surgery. While monitoring coagulation levels is important for patients on anticoagulant therapy, it is not the most critical intervention right after surgery when cardiac output and perfusion need to be closely monitored. Option D, monitoring for complications, is important but is not the priority over monitoring cardiac output in the immediate post-operative period. While complications need to be monitored for, ensuring adequate cardiac output takes precedence to prevent further complications related to inadequate perfusion. In an educational context, understanding the rationale behind prioritizing interventions post-CABG surgery is essential for nurses to provide safe and effective care to their patients. By prioritizing monitoring cardiac output, nurses can promptly identify and address any cardiac-related issues, ultimately contributing to better patient outcomes and recovery.

Correct Answer: A

Rationale: The correct answer is A) Teach the patient to keep the mask on during meals. This is important because interrupting oxygen therapy during meals can lead to a decrease in oxygen saturation levels, potentially causing hypoxia in the patient. Maintaining consistent oxygen delivery is crucial for patients who require supplemental oxygen to support their oxygenation needs. Option B) Keep the air entrainment ports clean and unobstructed, although important for maintaining the functionality of the Venturi mask, is not directly related to ensuring the correct amount of oxygen delivery in this specific scenario. Option C) Giving a high enough flow rate to keep the bag from collapsing is not necessary with a Venturi mask, as the device is designed to deliver a precise oxygen concentration regardless of the flow rate. Option D) Draining moisture condensation from the corrugated tubing every hour is important for preventing infection and maintaining the integrity of the equipment but does not directly impact the correct amount of oxygen delivery in this case. In an educational context, it is crucial for nurses to understand the principles of oxygen therapy and how to ensure appropriate oxygen delivery to patients. Teaching patients about the importance of consistent oxygen therapy, especially during meals, is a key aspect of providing safe and effective care to individuals requiring oxygen supplementation.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Administer pain medications. The priority in this situation is to address the patient's severe pain to ensure their comfort and well-being. Pain management is a crucial aspect of postoperative care as uncontrolled pain can lead to various complications and adversely affect the patient's recovery process. Option B) Administer subcutaneous insulin is incorrect as it is not the priority at this moment. While managing blood glucose levels is important in a postoperative patient, addressing severe pain takes precedence in this case. Option C) Administer pain relief is vague and does not specify a concrete action. Administering pain relief can encompass various interventions, but the priority is to provide pain medications promptly in this immediate situation. Option D) Monitor the patient's blood glucose levels is also not the priority when the patient is experiencing severe pain. While monitoring blood glucose levels is essential, it can be done after addressing the immediate concern of pain management. From an educational perspective, it is important for nurses to prioritize patient care based on the principle of addressing the most critical needs first. Understanding the hierarchy of needs helps nurses make informed decisions in providing safe and effective care to their patients. Prompt pain management is crucial in enhancing patient comfort, promoting recovery, and ensuring overall patient satisfaction.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Check the ventilator settings. This is the priority intervention because the patient's signs of respiratory distress indicate a potential issue with the mechanical ventilation. Checking the ventilator settings allows the nurse to assess if the settings are appropriate for the patient's current condition and make any necessary adjustments to improve oxygenation. Monitoring the patient's blood pressure (option B) is important in overall patient assessment, but in this case, addressing the respiratory distress takes precedence as it directly impacts oxygenation and can lead to serious complications if not managed promptly. Administering IV fluids (options C and D) is not the priority in this situation as the patient is experiencing respiratory distress, which requires immediate attention to ensure adequate oxygenation. IV fluids may be needed depending on the patient's overall condition, but addressing the respiratory distress should come first to prevent further deterioration. In an educational context, understanding the priority interventions in a critical care setting like mechanical ventilation is crucial for nurses to provide safe and effective care. By prioritizing actions based on the patient's condition, nurses can intervene promptly to optimize outcomes and prevent complications related to oxygenation.