Difficulty: Medium
Average Score: 77%
Simulated
Passage / Scenario
Nurses' NotesDay 1:
0900:
Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 Ib) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission.
Day 2:
Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema.
A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Which of the following findings should the nurse report to the provider?
Correct answer
A
Rationale
This is because tuberculosis can affect the liver and cause hepatotoxicity, especially if the client is taking anti-tuberculosis medications. The nurse should monitor the client's liver function tests, such as AST and ALT levels, and observe for signs of liver damage, such as yellow sclera, dark urine, clay-colored stools, and abdominal pain.