# A nurse is caring for a patient with active pulmonary tuberculosis who has been on anti-tuberculosis therapy for 8 weeks. The patient reports no symptoms, but routine laboratory results show elevated liver enzymes (ALT 120 U/L, AST 110 U/L). What is the most appropriate nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541357  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a patient with active pulmonary tuberculosis who has been on anti-tuberculosis therapy for 8 weeks. The patient reports no symptoms, but routine laboratory results show elevated liver enzymes (ALT 120 U/L, AST 110 U/L). What is the most appropriate nursing intervention?

## 보기

1. Hold the anti-tuberculosis medications and notify the healthcare provider immediately **✔ 정답**
2. Continue the current medication regimen and recheck liver enzymes in 2 weeks
3. Reduce the dosage of isoniazid by half and continue other medications
4. Administer hepatoprotective agents along with the current tuberculosis medications

**정답: 1**

## 해설

Significantly elevated liver enzymes (ALT 120 U/L, AST 110 U/L) indicate hepatotoxicity from anti-tuberculosis medications. Immediate discontinuation and provider notification are necessary to prevent severe liver damage.

## 심화 해설

Clinical Judgment
This question assesses the nurse's judgment in recognizing the serious adverse effect of drug-induced hepatotoxicity and prioritizing patient safety through immediate reporting and intervention. At week 6 of anti-tuberculosis treatment, the patient presents with clinical symptoms such as jaundice (yellowing of the eyes), fatigue, and nausea, along with markedly elevated liver enzyme levels of ALT 180 U/L, AST 165 U/L. These values exceed 3-5 times the upper limit of normal, posing a risk of progression to fulminant hepatic failure if the medication is continued. Therefore, the safest action is to **immediately hold** all potentially causative drugs and notify the physician to request a thorough evaluation and treatment plan adjustment.

Memory Tip
**H**epatotoxicity from **T**B drugs? **H**old all, **T**ell the doctor! Holding the medication is an important intervention within the **nurse's independent scope of judgment**.

KR vs US
In Korea, there may be more caution about discontinuing a medication without a physician's order change; however, in NGN/US nursing standards, when a clear life-threatening adverse effect occurs, the nurse has the authority and responsibility to hold the administration of that medication even before notifying the physician. 'Notify HCP' goes beyond simply informing; it must be accompanied by the necessary proactive measure (holding the drug).

## 임상 시나리오

Clinical Practice Guide: Managing Asymptomatic Transaminitis in TB Therapy

Assessment & Monitoring Protocol

- Obtain baseline liver function tests (ALT, AST, bilirubin, alkaline phosphatase) before initiating anti-TB therapy and repeat monthly, or more frequently if baseline values are abnormal or the patient has risk factors (e.g., pre-existing liver disease, alcohol use, older age).

- Educate patients to immediately report symptoms of hepatitis: jaundice, dark urine, right upper quadrant pain, nausea, vomiting, and unexplained fatigue. However, emphasize that significant injury can be asymptomatic, reinforcing the need for routine lab monitoring.

- When transaminases are elevated, perform a focused physical assessment for hepatomegaly, jaundice, and abdominal tenderness, and thoroughly review the patient's medication list for other hepatotoxic agents, including acetaminophen and alcohol.

Thresholds for Intervention

- **Asymptomatic with ALT/AST < 3 times the upper limit of normal (ULN):** Monitor closely, often with weekly liver function tests, and continue the standard regimen with heightened surveillance.

- **Asymptomatic with ALT/AST 3-5 times ULN:** This is a critical decision point. Many guidelines recommend holding all potentially hepatotoxic drugs (especially INH, RIF, PZA) and consulting the provider for a modified, less hepatotoxic regimen.

- **Symptomatic hepatitis or ALT/AST > 5 times ULN:** Immediately stop all hepatotoxic anti-TB medications. This is a medical emergency requiring urgent provider notification and alternative therapy planning.

Nursing Actions & Rechallenge Considerations

- Do not independently adjust, reduce, or split medication doses. The decision to reintroduce drugs sequentially (e.g., starting with rifampicin, then adding isoniazid) after liver enzymes normalize is a complex medical decision made by the physician or specialist.

- Ensure the patient's nutritional status is optimized and counsel on strict avoidance of alcohol, which synergistically increases the risk of severe hepatotoxicity.

- Document the adverse reaction thoroughly, including the specific drugs held, the date and time of provider notification, and the follow-up plan for liver function monitoring and treatment continuation.

## 핵심 개념

- **Hepatotoxicity** — A condition where liver cells are damaged by drugs or toxic substances. Antituberculosis medications (isoniazid, rifampin, pyrazinamide) are typical causative agents.
- **ALT (Alanine Aminotransferase)** — An enzyme primarily found in liver cells; when liver cells are damaged, it leaks into the bloodstream, causing levels to rise. It is a specific marker of liver injury.
- **AST (Aspartate Aminotransferase)** — An enzyme present in the liver, heart, muscles, etc. It also rises in liver damage, but its specificity is somewhat lower than ALT.
- **Anti-tuberculosis Therapy** — Drug therapy to treat tuberculosis. Initial treatment typically uses a four-drug combination therapy of Isoniazid, Rifampin, Ethambutol, and Pyrazinamide.
- **Notify HCP (Healthcare Provider)** — Reporting important clinical changes or test results to medical staff such as doctors or Advanced Practice Nurses (APN). This is a core nursing practice for patient safety.

## 같은 주제 문제

- [A 45-year-old patient with suspected pulmonary tuberculosis presents to the emergency depa…](https://mymerci.kr/pages/nclex_q.php?qn_id=541353)
- [A nurse is assessing a 38-year-old patient who has been receiving treatment for pulmonary …](https://mymerci.kr/pages/nclex_q.php?qn_id=541354)
- [A 65-year-old retired teacher presents to the emergency department with a 3-week history o…](https://mymerci.kr/pages/nclex_q.php?qn_id=541355)
- [A 45-year-old patient with suspected pulmonary tuberculosis presents to the emergency depa…](https://mymerci.kr/pages/nclex_q.php?qn_id=541356)
- [A nurse is assessing a patient with active pulmonary tuberculosis who has been on anti-tub…](https://mymerci.kr/pages/nclex_q.php?qn_id=541358)
- [A nurse is caring for a patient with community-acquired pneumonia who has been on antibiot…](https://mymerci.kr/pages/nclex_q.php?qn_id=541359)
- [A nurse is caring for a patient with active pulmonary tuberculosis who has been receiving …](https://mymerci.kr/pages/nclex_q.php?qn_id=541360)
- [A nurse is caring for a patient with active pulmonary tuberculosis who has been on anti-tu…](https://mymerci.kr/pages/nclex_q.php?qn_id=541361)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._