An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

Correct Answer: B

Rationale: The correct answer is B: Orange-colored sputum. This finding may indicate rifampin-induced discoloration of bodily fluids, a common side effect of TB medication. The healthcare provider should be notified to assess for possible liver toxicity. Yellow-tinged sclera (A) may indicate jaundice but is common with rifampin use. Thickening of the fingernails (C) is not typically associated with TB medication. Difficulty hearing high-pitched voices (D) is unrelated to TB treatment.

Correct Answer: C

Rationale: The correct answer is C: Monitor vital signs frequently. The priority intervention after a stroke is to closely monitor vital signs to detect any signs of deterioration or complications early on. This helps in providing timely interventions to prevent further harm. Performing a neurological assessment (A) can be important but not the immediate priority. Administering clot-busting medications (B) should be done within a specific time frame and requires proper patient evaluation first. Administering intravenous fluids (D) may be necessary, but monitoring vital signs takes precedence to ensure the patient's stability.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Maintaining the patient in the lateral position for 20 minutes after postural drainage with percussion and vibration helps to facilitate drainage of secretions from the affected lung segments. This position helps to target specific lung segments and allows gravity to assist in moving secretions towards larger airways for easier expectoration. Incorrect Choices: A: Scheduling the procedure 1 hour after the patient eats is not necessary for postural drainage with percussion and vibration. It is more important to maintain the patient in the proper position for effective drainage. C: Giving albuterol before therapy is not directly related to postural drainage with percussion and vibration. Albuterol is a bronchodilator that may be prescribed for bronchospasm but is not directly related to postural drainage. D: Performing percussion before assisting the patient to the drainage position is incorrect. Percussion should be performed after the patient is in the appropriate position to facilitate secretion movement.

Correct Answer: B

Rationale: The correct answer is B: Administer an opioid analgesic. The priority action for a patient with CKD experiencing fluid retention is to manage their pain with an opioid analgesic. Pain can exacerbate fluid retention by activating the sympathetic nervous system, leading to increased sodium and water retention. Administering an opioid analgesic can help alleviate the pain, reduce sympathetic activation, and potentially decrease fluid retention. Other choices are incorrect: A: Administer diuretics - While diuretics are commonly used for fluid retention in CKD, managing pain should take precedence in this scenario. C: Administer fluids and electrolytes - Administering more fluids can further worsen fluid retention in a patient with CKD. D: Administer a vasodilator - Vasodilators are not commonly used for fluid retention in CKD and may not address the underlying issue of pain.

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider. This is the priority intervention because postoperative nausea could indicate a serious complication that requires immediate attention from the healthcare provider. Administering antiemetics (A) may help relieve symptoms but does not address the underlying cause. Administering oral rehydration solutions (C) may be beneficial for dehydration but should not be the priority without knowing the cause of nausea. Administering a vasodilator (D) is not indicated for nausea and could potentially worsen the patient's condition.