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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: this is not an appropriate response because while it may reduce the intake of vitamin K, suddenly changing the client's diet drastically may not be necessary. It is essential for the healthcare provider to make any necessary adjustments to the medication based on the client's diet.
Choice B rationale: Warfarin is an anticoagulant medication that works by inhibiting the formation of blood clots. It interacts with vitamin K, which plays a crucial role in the blood clotting process. Leafy green vegetables are rich in vitamin K, and their consumption can affect the effectiveness of warfarin. The nurse should advise the client to inform her healthcare provider about her vegetarian diet and the regular consumption of leafy green vegetables. The healthcare provider will then be able to adjust the warfarin dosage accordingly to ensure that the client receives the appropriate and consistent level of anticoagulation.
Choice C rationale: while a vegetarian diet can be healthy, the specific concern here is the potential impact of vitamin K-rich foods on warfarin therapy. It's essential to address this potential interaction rather than focusing solely on the overall healthy lifestyle.
Choice D rationale: Consuming large amounts of leafy green vegetables and vitamin K-rich foods may actually reduce the effectiveness of warfarin, leading to a decreased ability to prevent blood clots. Therefore, it is crucial to consult with the healthcare provider to manage the dosage appropriately.
Correct Answer is A
Explanation
A. Scratchy throat: This symptom can indicate an allergic reaction, which can progress rapidly to more severe manifestations such as anaphylaxis. Anaphylaxis is a medical emergency that requires immediate intervention, including stopping the infusion and administering appropriate medications.
B. Pupillary constriction: This is not typically associated with an allergic reaction to medications like piperacillin-tazobactam. It is more commonly related to neurological conditions or the effects of certain drugs, such as opioids.
C. Hypertension: While elevated blood pressure can be concerning, it is not a common immediate reaction to piperacillin-tazobactam infusion. Hypertension could be related to other underlying conditions or stress but is not a primary reason to stop the infusion in this context.
D. Bradycardia: A slow heart rate is not a typical immediate response to an allergic reaction to antibiotics. Bradycardia can be caused by various factors, including medications, heart conditions, or electrolyte imbalances, but it is not directly linked to the infusion of piperacillin-tazobactam
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