The nurse is caring for a client who appears anxious and fearful. The client has recently been seen for a urinary tract infection and reports their urine has turned an orange-red color. What is the best response by the nurse?
"This may mean that your liver is failing and you need immediate medical attention."
"This is an expected finding for someone with a diet high in red meat.”
“This is a symptom that your urinary tract infection is worsening. I will notify the provider.”
“This is an expected finding if you are taking the over the counter medication, Phenazopyridine.”
The Correct Answer is D
A. "This may mean that your liver is failing and you need immediate medical attention." This statement is misleading; orange-red urine is not typically a sign of liver failure, especially in the context of a urinary tract infection.
B. "This is an expected finding for someone with a diet high in red meat." While diet can affect urine color, red meat is not commonly associated with orange-red urine; this is not a relevant response given the client's context.
C. “This is a symptom that your urinary tract infection is worsening. I will notify the provider.” While it is important to monitor urinary tract infections, orange-red urine is more likely related to the use of phenazopyridine rather than a worsening infection.
D. “This is an expected finding if you are taking the over-the-counter medication, Phenazopyridine.” Phenazopyridine is known to cause orange-red discoloration of urine, and this statement provides reassurance to the client regarding their symptoms
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Correct Answer is C
Explanation
A. Vitamin K: Vitamin K is used for anticoagulant reversal, not for acetaminophen toxicity.
B. Flumazenil: Flumazenil is a benzodiazepine antagonist and is not indicated for acetaminophen overdose.
C. Acetylcysteine: Acetylcysteine is the antidote for acetaminophen toxicity, helping to replenish glutathione stores and prevent liver damage.
D. Atropine: Atropine is used for bradycardia or certain poisoning but is not relevant for acetaminophen toxicity.
Correct Answer is B
Explanation
A. “If my breathing begins to feel tight, I will use the fluticasone immediately." Fluticasone is a corticosteroid, and it is not a rescue medication. It is used for long-term control and does not provide immediate relief for acute symptoms.
B. "I will be sure to use the albuterol nebulizer before the fluticasone." Albuterol is a bronchodilator and should be used first to open the airways, allowing better absorption of fluticasone when used afterward.
C. "I do not need to rinse my mouth after completing the albuterol and fluticasone." Rinsing the mouth after using fluticasone (a corticosteroid) is important to prevent oral thrush. Albuterol alone does not require rinsing, but fluticasone does.
D. "I will use both medications immediately after exercising." Albuterol is often used as a pre-exercise medication for asthma, but fluticasone should be used as directed for maintenance, not as an immediate post-exercise medication.