an older patient is receiving standard multidrug therapy for tuberculosis tb the nurse should notify the health care provider if the patient exhibits
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Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. 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: A

Rationale: The correct answer is 'Yellow-tinged skin.' Yellow-tinged skin is indicative of noninfectious hepatitis, a toxic effect of isoniazid (INH), rifampin, and pyrazinamide. If a patient on TB therapy develops hepatotoxicity, alternative medications will be necessary. Thickening of fingernails and difficulty hearing high-pitched voices are not typical side effects of the medications used in standard TB therapy. Presbycusis, age-related hearing loss, is common in older adults and not a cause for immediate concern. Orange-colored sputum is an expected side effect of rifampin and does not warrant immediate notification to the healthcare provider.

2. A healthcare professional has just received a medication order that is not legible. Which statement best reflects assertive communication?

Correct answer: B

Rationale: Assertive communication respects the rights and responsibilities of both parties. Choice B is the best example of assertive communication in this scenario. It addresses the issue directly by requesting clarification without blaming or devaluing the prescriber. This approach shows concern for safe practice and acknowledges the importance of clear communication in healthcare. Choices A, C, and D either involve self-depreciation, blaming the prescriber, or making demands without a respectful request for clarification, making them less effective in promoting effective communication and safe patient care.

3. The healthcare provider is managing a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be immediately reported to the healthcare provider?

Correct answer: D

Rationale: The critical finding that should be reported immediately to the healthcare provider is 'No measurable voiding in 4 hours.' This finding raises concerns about possible hyperkalemia, which can result from continued potassium administration and a decrease in urinary output. Hyperkalemia can lead to serious complications, including cardiac arrhythmias. The management of acute hyperkalemia involves interventions such as administering calcium to protect the heart, shifting potassium into cells, and enhancing potassium elimination from the body. The other choices do not indicate an urgent issue that requires immediate attention. Three episodes of vomiting in 1 hour can be concerning but may not be as immediately critical as the risk of hyperkalemia. Periodic crying and irritability are common in infants and may not indicate a severe complication. Vigorous sucking on a pacifier is a normal behavior in infants and does not signal a medical emergency.

4. A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition?

Correct answer: C

Rationale: Vomiting undigested food that is not bile stained and constipation are classic symptoms of pyloric stenosis. Stools that are ribbon-like and a child who is eating poorly are signs of congenital megacolon (Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic.

5. A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?

Correct answer: D

Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.

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