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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Tamsulosin is an alpha-blocker that relaxes the smooth muscles of the prostate and bladder neck, improving urine flow. However, it can also cause hypotension, dizziness, and fainting as adverse effects. Therefore, monitoring blood pressure is essential for clients taking tamsulosin.

Choice B rationale

While assessing the client’s urine output is an important part of monitoring a client with benign prostatic hyperplasia, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice C rationale

Performing a bladder scan can be useful in assessing the client’s urinary retention, a common symptom of benign prostatic hyperplasia. However, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice D rationale

Obtaining the client’s daily weights can be useful in monitoring fluid balance, but it is not specifically related to monitoring for adverse reactions to tamsulosin.

A. Administer sucralfate once daily, preferably at bedtime. B. Give sucralfate on an empty stomach. C. Monitor for a secondary Candida infection. D. Monitor for electrolyte imbalances.

Correct Answer is B

Explanation

Choice A rationale

Sucralfate is not typically administered once daily, preferably at bedtime. It is usually given multiple times a day.

Choice B rationale

Sucralfate should be given on an empty stomach, at least one hour before meals and at bedtime. This is because the absorption of sucralfate can be affected by the presence of food in the stomach.

Choice C rationale

While it’s important to monitor for infections when administering any medication, there’s no specific association between sucralfate and secondary Candida infections.

Choice D rationale

Sucralfate does not typically cause electrolyte imbalances. Its main function is to form a protective barrier over the ulcer, preventing further damage from acid and pepsin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with benign prostatic hyperplasia has been prescribed tamsulosin. What should the nurse do to monitor for an adverse reaction?

Correct Answer is A

Explanation

The nurse is preparing to administer the anti-ulcer gastrointestinal agent sucralfate to a patient with peptic ulcer disease.What should be included in this patient’s care plan?

Correct Answer is B

Explanation

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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?