Correct Answer: C

Rationale: The priority action for the nurse when time is limited is to focus on essential teaching. In this scenario, the patient should be educated on how to self-monitor glucose levels and administer medications to control glucose levels. While diet, exercise, medications, and potential complications are important topics for further education, these can be addressed through appropriate referrals and future teaching sessions.

Correct Answer: B

Rationale: The correct advice for a patient starting rifampin is to expect orange-red discoloration of body fluids. Rifampin can cause harmless orange-red discoloration of body fluids, which may include urine, sweat, saliva, and tears. It is important for the patient to be aware of this side effect as it can stain clothing and contact lenses. Limiting intake of green leafy vegetables is not necessary with rifampin. Avoiding exposure to sunlight is more commonly associated with other medications like tetracyclines. Taking rifampin with antacids is not recommended as antacids can reduce the absorption of rifampin.

Correct Answer: B

Rationale: Jaundice in a client with liver cirrhosis is primarily caused by increased bilirubin levels. In liver cirrhosis, the impaired liver function leads to the accumulation of bilirubin in the blood, resulting in jaundice. Bilirubin is a yellow pigment produced from the breakdown of red blood cells, and its elevation is a common manifestation of liver dysfunction.

Correct Answer: B

Rationale: Patients prescribed lithium should maintain a consistent salt intake to help stabilize lithium levels. Fluctuations in salt intake can affect the levels of lithium in the body, potentially leading to toxicity or reduced effectiveness of the medication. It is important for patients to be consistent with their salt intake and to avoid sudden increases or decreases.

Correct Answer: B

Rationale: Nausea and vomiting are common signs of digoxin toxicity, which can lead to serious complications like dysrhythmias. Prompt intervention is crucial to prevent further harm to the client.