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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: This is not appropriate because the client's elevated calcium level requires immediate attention and further assessment by the healthcare provider before administering any medications that may further raise calcium levels.
Choice B rationale: The client's total calcium level is significantly elevated, which may indicate hypercalcemia. Given the reference range for total calcium in adults is 9 to 10.5 mg/dL (2.25 to 2.62 mmol/L), a calcium level of 14 mg/dL (3.5 mmol/L) is abnormally high. Both calcitriol (active form of vitamin D) and calcium carbonate (calcium supplement) can increase calcium levels in the body. Before administering any medication, the nurse should hold both calcitriol and calcium carbonate and notify the healthcare provider of the elevated calcium level. The healthcare provider will determine the appropriate course of action and may adjust the dosage or temporarily discontinue the medications to prevent further complications related to hypercalcemia.
Choice C rationale: Holding calcium carbonate is a step in the right direction, but given the significant elevation of total calcium, it is best to hold both medications and consult the healthcare provider.
Choice D rationale: Holding calcitriol is a step in the right direction, but both medications should be held to prevent exacerbation of hypercalcemia until further instructions are received from the healthcare provider.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Indicated Instructions:
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Hold spironolactone for 3 days (Choice D):
- Reasoning: Captopril, an ACE inhibitor, can increase potassium levels. Spironolactone is a potassium-sparing diuretic. Holding spironolactone helps prevent hyperkalemia (high potassium levels), which can be dangerous.
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Lay down if the blood pressure drops quickly after the first dose (Choice E):
- Reasoning: Captopril can cause a significant drop in blood pressure, especially after the first dose. Lying down helps prevent dizziness and fainting (orthostatic hypotension) due to the sudden decrease in blood pressure.
Contraindicated Instructions:
-
Increase the lantus dose by 3 units the morning of the first dose (Choice B):
- Reasoning: Adjusting insulin (Lantus) dose is not related to the administration of captopril and could potentially cause blood sugar imbalances. Such a change should be based on blood glucose monitoring, not the initiation of captopril.
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Limit fluids for several days before the first dose (Choice C):
- Reasoning: Limiting fluids can lead to dehydration, which can exacerbate the hypotensive effects of captopril. Maintaining adequate hydration is important to avoid severe drops in blood pressure.
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Monitor blood pressure for several hours after the first dose (Choice B):
- Reasoning: Monitoring blood pressure ensures that any significant hypotensive response (drop in blood pressure) to the initial dose of captopril is identified and managed promptly.
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