While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Check the client's capillary glucose level.

Use a pulse oximeter to assess oxygen saturation.

Report the finding to the healthcare provider.

Advise the client to reduce the medication dose.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Checking the capillary glucose level is not relevant to the observation of yellow skin color. Jaundice is related to liver function, not glucose levels.

Choice B rationale: Oxygen saturation measurement is not relevant to the observation of yellow skin color. It is used to assess the oxygen-carrying capacity of the blood, not liver function.

Choice C rationale: Yellow discoloration of the skin (jaundice) can be indicative of liver dysfunction or damage. Since the client takes acetaminophen for chronic pain, which is metabolized in the liver, the nurse should be concerned about potential hepatotoxicity. Reporting the findings to the healthcare provider is essential for further evaluation and management.

Choice D rationale: Reducing the medication dose is not appropriate without further evaluation and guidance from the healthcare provider. Jaundice may indicate liver dysfunction, and altering the medication without professional assessment could be unsafe.

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Correct Answer is C

Explanation

A. A scratchy throat may indicate mild irritation but is not an immediate reason to stop the infusion unless it progresses.
B. Pupillary constriction is not typically associated with an acute reaction to piperacillin-tazobactam.
C. A sudden increase in blood pressure (hypertension) during the infusion may indicate a serious adverse reaction and is a valid reason to stop the infusion immediately and notify the provider.
D. Bradycardia is not commonly associated with piperacillin-tazobactam infusion reactions and would not automatically warrant stopping the infusion.

A. Administer the dose and monitor the client's BP regularly. B. Withhold the scheduled dose and notify the healthcare provider. C. Apply a telemetry monitor before administering the dose. D. Assess for orthostatic hypotension before administering the dose.

Correct Answer is B

Explanation

Choice A rationale: Administering the dose of labetalol without further assessment may not be appropriate in this situation. The client's heart rate is 48 beats/minute, which is considered bradycardia (heart rate below the normal range of 60-100 beats/minute). Bradycardia can be a potential adverse effect of labetalol, a beta-blocker. Moreover, the client's blood pressure is elevated at 150/90 mm Hg, indicating that the hypertension is not well controlled. Administering the dose without addressing the bradycardia or elevated blood pressure could potentially exacerbate these issues.

Choice B rationale: Withholding the scheduled dose of labetalol is the most appropriate action in this scenario. The client's heart rate of 48 beats/minute is considered bradycardia, which may be a side effect of labetalol or indicative of an underlying issue. Additionally, the client's blood

pressure is elevated, indicating inadequate control of hypertension. Bradycardia can reduce cardiac output and may lead to further complications. Notifying the healthcare provider is essential to obtain further instructions and address the client's bradycardia and hypertension before administering the medication.

Choice C rationale: While telemetry monitoring is appropriate for clients with certain cardiac conditions or when changes in heart rate need close observation, it may not be the most urgent action in this situation. The client's bradycardia and elevated blood pressure are concerning and require immediate attention. Telemetry monitoring may be considered later, but it does not address the immediate need to withhold the medication and seek guidance from the healthcare provider.

Choice D rationale: Orthostatic hypotension refers to a drop in blood pressure when changing positions, such as from lying down to standing up. While orthostatic hypotension is a valid concern for clients taking antihypertensive medications, it is not the primary issue in this scenario. The client's heart rate is 48 beats/minute, indicating bradycardia and the blood pressure is elevated at 150/90 mm Hg, suggesting uncontrolled hypertension. These are the main concerns that require immediate attention and further assessment before administering the labetalol dose.

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While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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