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 ["C","D"]
Explanation
Choice A rationale: Crushing ciprofloxacin tablets may interfere with their efficacy, and it is generally not recommended to alter the dosage form without consulting a healthcare provider.
Choice B rationale: Ciprofloxacin may cause joint aches and pains, but using non-steroidal anti-inflammatory drugs (NSAIDs) is generally not advised as they can interact with the medication and increase the risk of adverse effects.
Choice C rationale: Ciprofloxacin is associated with the risk of tendonitis and tendon rupture. Therefore, any tendon pain or swelling should be reported immediately to the healthcare provider.
Choice D rationale: Increasing fluid intake while taking ciprofloxacin can help prevent crystalluria, a potential side effect of the medication.
Choice E rationale: Ciprofloxacin can make the skin more sensitive to sunlight, leading to an increased risk of sunburn. Patients should limit exposure to sunlight and avoid tanning beds while taking this medication.
Correct Answer is A
Explanation
Choice A rationale: Baclofen is a muscle relaxant used to reduce muscle spasticity in conditions such as multiple sclerosis. One of the common side effects of baclofen is dizziness or orthostatic hypotension, which can increase the risk of falls. Therefore, the nurse should advise the client to move slowly and cautiously when rising and walking to prevent falls and injury.
Choice B rationale: Monitoring intake and output every 8 hours is not directly related to the administration of baclofen.
Choice C rationale: Ensuring the client knows to stop baclofen before using other antispasmodics is not the correct intervention. Baclofen should not be abruptly discontinued without medical advice, and its use should be discussed with the healthcare provider.
Choice D rationale: Evaluating muscle strength every 4 hours may be part of the client's overall care plan, but it is not directly related to the administration of baclofen. Muscle strength evaluation is more pertinent for assessing the progression of multiple sclerosis and its effects on muscle function.
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