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    Ati rn adult medical surgical 2023 proctored exam

    A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

    Explanation & Rationale

    Rationale: A. "This finding may indicate possible medication toxicity." The red-orange color of the saliva is not indicative of toxicity but is a known, harmless side effect of rifampin. The nurse should reassure the client that this color change is common and not a sign of toxicity. B. "This is an expected adverse effect of this medication." Rifampin can cause body fluids, including saliva, urine, and sweat, to turn a red-orange color. This is a well-known, expected adverse effect of the medication and does not require discontinuation or interventions. C. "You will need to increase your fluid intake to resolve this problem." Increasing fluid intake will not affect the color change in body fluids caused by rifampin. The change in color is a benign side effect, and fluid intake does not resolve this issue. D. "Your provider will prescribe a different medication regimen." The red-orange discoloration is a common side effect of rifampin and is not harmful. There is no need to change the medication regimen unless the client experiences other more serious side effects.

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