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.

Answer and Explanation

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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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.

A. Monitor skin for excessive bruising. B. Replace salt with a salt substitute. C. Cover your skin before going outside. D. Limit intake of high-potassium foods.

Correct Answer is D

Explanation

Choice A rationale: This instruction is not directly related to spironolactone use or hyperaldosteronism. Excessive bruising may be relevant in some situations but not specifically for this scenario.
Choice B rationale: While heart failure patients are often advised to reduce their sodium intake, the use of a salt substitute (potassium-based) would be contraindicated in this case due to the risk of hyperkalemia.
Choice C rationale: This instruction is not directly related to spironolactone use or
hyperaldosteronism. It may be relevant for sun protection, but it is not a priority in this context.
Choice D rationale: Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium while excreting sodium and water. Since the client has heart failure (HF), there is a risk of hyperkalemia (high potassium levels) associated with spironolactone use. To prevent this, the nurse should instruct the client to limit their intake of high-potassium foods, such as bananas, oranges, tomatoes, spinach, and other potassium-rich foods.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client's plan of care?

Correct Answer is D

Explanation

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