# Situation: A public health nurse at a Rural Health Unit (RHU) manages clients enrolled in the National Tuberculosis Program (NTP). Many of them live in crowded urban households. The nurse teaches a client newly started on 2HRZE for infectious pulmonary tuberculosis about the drugs and home care. Which statement shows that the client needs **FURTHER** teaching?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627027  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A public health nurse at a Rural Health Unit (RHU) manages clients enrolled in the National Tuberculosis Program (NTP). Many of them live in crowded urban households.

The nurse teaches a client newly started on 2HRZE for infectious pulmonary tuberculosis about the drugs and home care. Which statement shows that the client needs **FURTHER** teaching?

## 보기

1. "I will stop the tablets and go to the clinic if my eyes turn yellow."
2. "I will bring my family to the clinic so they can be checked too."
3. "I will stop the tablets and see the doctor if my urine turns orange." **✔ 정답**
4. "I will sleep in a separate room with the window open for now."

**정답: 3**

## 해설

Orange-red urine, sweat, and tears are an expected, harmless effect of rifampicin; stopping treatment because of it risks relapse and drug resistance. Yellow eyes suggest drug-induced hepatotoxicity, which does require withholding the drugs and prompt referral. Sleeping in a separate ventilated room and having household contacts screened are correct.

## 심화 해설

Understanding the question

The client is newly started on the standard intensive phase of tuberculosis treatment: 2HRZE. This stands for two months of isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E). The question asks which statement indicates a need for further teaching, meaning the client has misunderstood something important about the drugs or home infection control.

The correct answer is statement 3 because orange urine is a normal, expected effect of rifampicin, not a reason to stop treatment. Stopping the drugs because of this harmless discoloration would interrupt therapy and increase the risk of treatment failure, relapse, and drug resistance.

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Why orange urine is not a danger sign

Rifampicin and its metabolites are highly pigmented. They are excreted through the kidneys, liver, sweat glands, and lacrimal glands. This causes body fluids such as urine, sweat, tears, and sometimes saliva to turn an orange-red color. This effect begins shortly after starting the drug and continues throughout treatment.

The discoloration is pharmacologically expected and does not indicate liver injury, kidney damage, or any other organ toxicity. It is not a hypersensitivity reaction. The client should be reassured that this is harmless and that they must continue taking all tablets as prescribed.

If the client stops rifampicin because of orange urine, the consequences are serious. Key point! Interrupted treatment allows surviving mycobacteria to multiply again. This can lead to prolonged infectiousness, clinical relapse, and the emergence of drug-resistant strains. Non-adherence to tuberculosis treatment is a major driver of treatment failure and acquired drug resistance.

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When stopping the drugs is correct

Statement 1 describes yellowing of the eyes, which is scleral icterus. This is a sign of hyperbilirubinemia, most commonly caused by drug-induced liver injury. In the 2HRZE regimen, the main hepatotoxic agents are isoniazid, rifampicin, and pyrazinamide. Liver injury can progress to severe hepatitis if the offending drugs are continued.

Yellow eyes or skin, dark urine, persistent nausea or vomiting, abdominal pain, and unexplained fatigue are warning signs that require withholding the anti-TB drugs and immediate medical evaluation. The client’s statement that they would stop the tablets and go to the clinic for yellow eyes is therefore correct and shows good understanding.

Watch out! Do not confuse the orange-red discoloration from rifampicin with the dark, tea-colored urine of bilirubinuria. Orange urine is bright and reddish-orange; bilirubinuria is typically dark brown or cola-colored. The client’s statement about orange urine is the one that reflects a misunderstanding.

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Home infection control and contact screening

Statement 2 is correct. Pulmonary tuberculosis is transmitted through airborne droplet nuclei. Household contacts, especially those living in crowded conditions, are at high risk of infection. All close contacts should be evaluated for latent TB infection or active disease. This is a standard component of TB control programs.

Statement 4 is also correct. During the first two weeks of effective treatment, the client remains potentially infectious. Sleeping in a separate room with an open window reduces the concentration of infectious droplet nuclei in shared household air. Natural ventilation dilutes and removes airborne bacilli, lowering transmission risk to family members. After two weeks of adherent treatment with clinical improvement, the client is generally considered much less infectious.

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Why adherence education matters

Patient education is a core nursing intervention for tuberculosis. It improves understanding of the disease, the purpose of each drug, expected side effects versus danger signs, and the importance of completing the full course. Education that distinguishes harmless effects such as orange urine from serious adverse events such as jaundice helps prevent unnecessary treatment interruption. Clear teaching about infection control measures and contact screening also protects the household and the community.

The table below summarizes the key distinctions the client must understand.

| Finding | Cause | Expected or dangerous | Correct action |
| --- | --- | --- | --- |
| Orange-red urine, sweat, tears | Rifampicin pigment excretion | Expected and harmless | Continue all drugs; reassure client |
| Yellow eyes or skin | Drug-induced hepatotoxicity (H, R, Z) | Dangerous | Stop drugs; refer immediately |
| Dark, tea-colored urine | Bilirubinuria from liver injury | Dangerous | Stop drugs; refer immediately |
| Persistent nausea, vomiting, abdominal pain | Possible hepatitis | Dangerous | Stop drugs; refer immediately |

The client who plans to stop treatment for orange urine has not yet understood that this is an expected effect of rifampicin. That misunderstanding, if acted upon, would directly undermine treatment success and increase the risk of drug-resistant tuberculosis.

## 임상 시나리오

Rifampicin Body Fluid DiscolorationExpected effect vs. danger signs in TB treatment
Orange-red urine, sweat, and tears are a harmless, expected effect of rifampicin. The client must continue all tablets as prescribed.

Stopping treatment because of discoloration risks relapse and drug resistance. Reassure the client that this is not organ toxicity or allergy.

CautionYellow eyes suggest drug-induced hepatotoxicity and require withholding the drugs and prompt referral.

## 핵심 개념

- **2HRZE** — Standard intensive phase of TB treatment: 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol.
- **Rifampicin** — Anti-TB drug that causes harmless orange-red discoloration of urine, sweat, and tears.
- **Hepatotoxicity** — Drug-induced liver injury, signaled by yellow eyes or jaundice, requiring prompt referral.
- **Drug resistance** — A serious consequence of interrupted TB treatment, allowing mycobacteria to survive and multiply.
- **NTP** — National Tuberculosis Program, the public health framework for TB management.

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