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 C

Explanation

Choice A rationale: Nausea is the symptom the medication is intended to treat, and it is expected that the client may have some level of nausea while undergoing chemotherapy. It is not the most important adverse effect to report in this scenario.

Choice B rationale: Diarrhea is not a common or significant adverse effect of metoclopramide. While it is essential to monitor for any gastrointestinal side effects, it is not the most important adverse effect to report in this case.

Choice C rationale: Metoclopramide is a medication commonly used to treat nausea and vomiting, particularly related to chemotherapy. One of the significant adverse effects of metoclopramide is the potential to cause extrapyramidal symptoms, including involuntary movements such as dystonia, dyskinesia, and Parkinsonism. These extrapyramidal symptoms can be serious and may require immediate intervention or discontinuation of the medication.

Therefore, it is essential for the nurse to closely monitor the client for any signs of involuntary movements and report them promptly to the healthcare provider for appropriate management.

Choice D rationale: Unusual irritability is not a typical adverse effect associated with metoclopramide. While mood changes can occur with any medication, involuntary movements are a more concerning side effect that requires immediate attention and reporting.

A. Administer both prescribed medications as scheduled. B. Hold both medications until contacting the healthcare provider. C. Hold the calcium carbonate, but administer the calcitriol as scheduled. D. Hold the, calcitriol but administer the calcium carbonate as scheduled.

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.

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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

A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

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Exhibits The nurse is preparing the client for discharge and discussing home medications. What home medications may affect the amount of insulin needed by the client? Select all that apply.

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?

The nurse reviews the lab values. Exhibits What questions can the nurse ask the client based on the lab results? Select all that apply.