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: C

Rationale: The correct answer is C) Explain that orange discolored urine and tears are normal while taking this medication. This response demonstrates accurate knowledge about rifampin, a medication commonly used to treat tuberculosis. Rifampin is known to cause harmless side effects such as orange discoloration of bodily fluids, including urine and tears. By explaining this to the patient, the nurse can alleviate concerns and provide reassurance, promoting medication adherence and patient education. Option A) Asking about visual changes in red-green color discrimination is unrelated to the side effects of rifampin and tuberculosis treatment, making this option incorrect. Option B) Inquiring about shortness of breath, hives, or itching is not relevant to the known side effects of rifampin, so this response is incorrect and could lead to unnecessary concern for the patient. Option D) Advising the patient to stop the drug and report symptoms to the healthcare provider is incorrect because the side effects of orange discoloration of urine and tears are expected with rifampin therapy and do not warrant discontinuation of the medication without proper assessment by a healthcare provider. In an educational context, understanding the side effects of medications is crucial for nurses to provide accurate information to patients. By explaining expected side effects like orange discoloration of bodily fluids, nurses can enhance patient understanding, compliance, and overall therapeutic outcomes.

Correct Answer: D

Rationale: The correct answer is D) The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone. This answer is correct because using albuterol in the yellow zone indicates appropriate self-management of asthma exacerbation. Albuterol is a rescue medication that helps to open up the airways quickly during an asthma attack or when peak flow readings drop into the yellow zone, signaling a cautionary phase. Option A is incorrect because inhaling rapidly through the peak flow meter mouthpiece does not reflect proper technique. Option B is incorrect as montelukast is a long-term control medication and is not typically used for immediate symptom relief in the red zone. Option C is also incorrect as calling the healthcare provider when in the green zone is unnecessary as this zone indicates good lung function. Understanding peak flow meter readings and knowing how to respond appropriately based on the zones is crucial in managing asthma effectively. Educating patients on using rescue medications like albuterol in the yellow zone can help prevent asthma exacerbations and improve overall respiratory health.

Correct Answer: D

Rationale: The correct answer is D because the patient's asthma is not well-controlled with only short-acting bronchodilators like albuterol (Ventolin HFA) and long-acting bronchodilators like salmeterol (Serevent). This combination does not address the underlying inflammation in asthma. The patient needs an inhaled corticosteroid as maintenance therapy to control inflammation and prevent exacerbations. Option A is incorrect because using albuterol before exercise is a common practice to prevent exercise-induced bronchospasm in asthma patients. Option B is incorrect because worsening symptoms in spring could be related to seasonal allergens triggering asthma, which may require adjustment in therapy, but it does not necessarily indicate a need for an immediate change. Option C is incorrect because an increase in heart rate after using albuterol is an expected side effect due to its bronchodilator properties and does not necessarily indicate a need for a change in therapy unless there are other concerning symptoms present. In an educational context, it is vital for nurses to understand asthma management principles to provide optimal care for patients. Recognizing when a patient's current therapy is inadequate and needs adjustment is crucial in preventing asthma exacerbations and improving quality of life. Incorporating evidence-based guidelines in asthma management helps nurses make informed decisions in patient care.

Correct Answer: D

Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99.' After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.

Correct Answer: A

Rationale: In caring for a patient with a tracheostomy tube, maintaining safe cuff pressure is essential to prevent complications such as tracheal mucosal damage or aspiration. The correct answer, option A, "Measure with a manometer," is the most appropriate way to ensure safe cuff pressure. Using a manometer allows the nurse to accurately measure the pressure inside the cuff of the tracheostomy tube. This is crucial because overinflating the cuff can lead to tracheal damage, while underinflation can result in aspiration of secretions. Therefore, regular monitoring and adjustment of cuff pressure using a manometer is the recommended practice to ensure patient safety. Option B, "Insert decannulation plug," is incorrect as a decannulation plug is used to block the tracheostomy tube during temporary removal, not for monitoring cuff pressure. Option C, "Obtain a provider's order," is incorrect because while healthcare provider input is important in many situations, routine monitoring and adjustment of cuff pressure can and should be done by the nurse based on best practices. Option D, "Use a nonfenestrated cannula," is incorrect as it pertains to a different aspect of tracheostomy care and does not address cuff pressure monitoring. Educationally, it is essential for nurses to understand the proper care and management of tracheostomy tubes to ensure patient safety and optimal outcomes. Regular assessment, monitoring, and maintenance of cuff pressure are key components of tracheostomy care that nurses should be proficient in to provide high-quality care to patients with artificial airways.