# A nurse is caring for a patient with active pulmonary tuberculosis who has been on anti-tuberculosis therapy for 6 weeks. The patient reports persistent fatigue, nausea, and yellowing of the eyes. Laboratory results show elevated liver enzymes (ALT 180 U/L, AST 165 U/L). What is the most appropriate nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541852  
> 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 6 weeks. The patient reports persistent fatigue, nausea, and yellowing of the eyes. Laboratory results show elevated liver enzymes (ALT 180 U/L, AST 165 U/L). What is the most appropriate nursing intervention?

## 보기

1. Continue current medications and monitor liver enzymes weekly
2. Reduce the dosage of all anti-tuberculosis medications by half
3. Discontinue isoniazid only and continue other medications
4. Hold all anti-tuberculosis medications and notify the physician immediately **✔ 정답**

**정답: 4**

## 해설

The patient shows signs of drug-induced hepatotoxicity (fatigue, nausea, jaundice, elevated ALT/AST) from anti-TB therapy. Immediate intervention is required to prevent liver failure. Other options are inappropriate as they delay treatment or adjust dosages without physician input.

## 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
Regular monitoring of liver function tests (LFTs) is standard when starting and during anti-tuberculosis treatment. The hepatotoxicity management algorithm depends on the presence of symptoms and the degree of liver enzyme elevation: 1) Asymptomatic & liver enzymes < 5x ULN (upper limit of normal): Continue treatment with careful monitoring. 2) Asymptomatic & liver enzymes ≥ 5x ULN: Discontinue medication and evaluate. 3) If symptomatic hepatitis (jaundice, nausea, fatigue, etc.) is present, immediately stop all medications and notify the physician regardless of liver enzyme levels.
Caution
In SATA (Select All That Apply) questions, the option "monitor" is a common pitfall. In a situation with already obvious symptoms and severe lab value elevations, simply monitoring constitutes an **inappropriate delay**. Also, **the nurse should not independently adjust (reduce) the medication dosage**.

## 핵심 개념

- **Drug-Induced Hepatotoxicity** — Liver injury caused by drugs. Antituberculosis medications (isoniazid, rifampin, pyrazinamide), some antibiotics, and analgesics can be the cause, and it presents with jaundice, nausea, fatigue, and elevated liver enzymes.
- **Isoniazid** — First-line antituberculosis drug. It is metabolized through liver metabolic enzymes (CYP450), and major side effects include peripheral neuritis and hepatotoxicity. Vitamin B6 (Pyridoxine) is co-administered to prevent neuritis.
- **Alanine Aminotransferase (ALT) / Aspartate Aminotransferase** — It is an enzyme present in liver cells. When liver cells are damaged, it leaks into the bloodstream, causing levels to rise. It is a sensitive indicator of liver damage. The normal range is generally around 7–40 U/L, and the level in the case is 4–5 times the normal value.
- **Jaundice** — Jaundice. A condition where the skin, sclera (whites of the eyes), and mucous membranes appear yellow due to elevated blood bilirubin levels. Causes include liver dysfunction, bile duct obstruction, and hemolysis; here, it suggests hepatocellular jaundice due to liver cell damage.
- **Hold Medication** — The act of withholding or discontinuing medication administration. This is an important nursing intervention taken when potential risks to the patient are anticipated. After notifying the physician, the medication is resumed or adjusted according to the physician's orders.

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