While evaluating a patient who has been taking acetaminophen for chronic pain, the nurse notices that the patient’s skin appears yellow.
What action should the nurse take in response to this observation?
Suggest the patient to reduce the dosage of the medication.
Check the patient’s capillary glucose level.
Use a pulse oximeter to assess the patient’s oxygen saturation.
Report the observation to the healthcare provider.
The Correct Answer is D
Choice A rationale
While reducing the dosage of a medication might be appropriate in some cases, it’s not the best initial action when a patient’s skin appears yellow. Yellowing of the skin, or jaundice, can be a sign of liver damage, which can be a serious side effect of acetaminophen. The healthcare provider should be notified before any changes are made to the medication regimen.
Choice B rationale
Checking the patient’s capillary glucose level would not be the most appropriate response to the observation of yellow skin. While it’s important to monitor glucose levels in patients with certain conditions, such as diabetes, it would not provide information about potential liver damage, the likely cause of the patient’s yellow skin.
Choice C rationale
Using a pulse oximeter to assess the patient’s oxygen saturation would not provide information about the cause of the patient’s yellow skin. While it’s an important assessment in many situations, it would not help in identifying potential liver damage from acetaminophen use.
Choice D rationale
This is the most appropriate action. Yellowing of the skin can be a sign of liver damage, a potential side effect of acetaminophen. The healthcare provider should be notified of this observation as soon as possible for further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypertension, or high blood pressure, is not typically a side effect of piperacillin-tazobactam. While it’s important to monitor a client’s blood pressure during any infusion, hypertension alone would not typically be a reason to stop the infusion of piperacillin-tazobactam.
Choice B rationale
A scratchy throat could be a sign of an allergic reaction to piperacillin-tazobactam. Allergic reactions to medications can range from mild to severe, and can include symptoms such as hives, difficulty breathing, and swelling in the face or throat. If a client reports a scratchy throat shortly after starting an infusion of piperacillin-tazobactam, it would be prudent for the nurse to stop the infusion and assess the client for other signs of an allergic reaction.
Choice C rationale
Bradycardia, or a slow heart rate, is not typically a side effect of piperacillin-tazobactam. While it’s important to monitor a client’s heart rate during any infusion, bradycardia alone would not typically be a reason to stop the infusion of piperacillin-tazobactam.
Choice D rationale
Pupillary constriction is not typically a side effect of piperacillin-tazobactam. While it’s important to monitor a client’s pupils during any infusion, pupillary constriction alone would not typically be a reason to stop the infusion of piperacillin-tazobactam.
Correct Answer is D
Explanation
Choice A rationale
While a coronary artery bypass procedure is a significant event in a patient’s medical history, it occurred in 1995, which is quite some time ago. Therefore, it may not be the most significant piece of data when planning this client’s care, given their current signs and symptoms.
Choice B rationale
A colonoscopy performed for routine screening six months ago is unlikely to be related to the client’s current symptoms of nausea, vomiting, and anorexia. Therefore, this choice is not the most significant piece of data when planning this client’s care.
Choice C rationale
Depression following the death of a spouse can significantly impact a person’s mental health. However, this event occurred in 1999, and while it may contribute to the client’s overall health status, it is not likely to be the most significant piece of data for planning care based on the client’s current symptoms.
Choice D rationale
The client has been taking digoxin and furosemide daily since 19962. Both of these medications are used to treat heart conditions. Digoxin strengthens the heart’s contractions, while furosemide is a diuretic that helps reduce fluid buildup. Given the client’s symptoms of nausea, vomiting, and anorexia, and their diagnosis of heart failure, this information is crucial. These symptoms could indicate a worsening of heart failure or side effects of the medication, which would significantly influence the plan of care.
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