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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is D. Immediately after completion of the IV dose and 30 minutes before the next administration of the medication.

Explanation:

Peak levels measure the highest concentration of the drug in the bloodstream and should be drawn immediately after the IV infusion is completed.
Trough levels measure the lowest concentration of the drug and should be drawn 30 minutes before the next scheduled dose. This helps ensure the drug remains within therapeutic levels and prevents toxicity.

Why the other options are incorrect:

A. One hour after completion of the IV dose and one hour before the next administration – Waiting one hour for the peak level is too long and may lead to an inaccurate measurement.
B. Two hours after completion of the IV dose and two hours before the next administration – Waiting two hours for both peak and trough levels is too late for effective monitoring.
C. Thirty minutes into the administration of the IV dose and 30 minutes before the next administration – The sample drawn mid-infusion does not represent peak levels, making this method ineffective.

Key takeaway:

Proper timing of vancomycin peak and trough monitoring ensures therapeutic drug levels while minimizing nephrotoxicity and ototoxicity.

A. For long-term control of pain and swelling. B. Until a smaller angle can be restored. C. Until the excess pressure is reduced. D. For long-term control of normal eye pressure.

Correct Answer is D

Explanation

Choice A rationale

Eye drops for glaucoma are not typically used for long-term control of pain and swelling.

Choice B rationale

Restoring a smaller angle is not the goal of treatment for open-angle glaucoma.

Choice C rationale

While reducing excess pressure is a goal of glaucoma treatment, eye drops are typically used for long-term control rather than a temporary reduction of pressure.

Choice D rationale

Eye drops for open-angle glaucoma are used for long-term control of normal eye pressure. They need to be used every day, and depending on the type of medicine, may need to be used once, twice, or up to 4 times a day.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 is receiving intravenous vancomycin, and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times would provide the best determination of these levels?

Correct Answer is D

Explanation

Explanation:

Why the other options are incorrect:

Key takeaway:

A patient with open-angle glaucoma asks the nurse about the duration of use for the prescribed eye drops. What is the nurse’s accurate response?

Correct Answer is D

Explanation

The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?

When administering medications to a group of patients, which patient should the nurse closely monitor for the development of acute kidney injury (AKI)?

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

A patient with heart failure develops hyperaldosteronism and is prescribed spironolactone.What instructions should the nurse include in the patient’s care plan?

A patient with peptic ulcer disease has been prescribed cimetidine.Which statement made by the patient indicates the need for further instruction by the nurse?

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?

A female patient who follows a vegetarian diet has recently been prescribed warfarin. She mentions that she consumes leafy green vegetables daily.What should be the nurse’s response?

A client taking atorvastatin has an increased serum creatine phosphokinase (CK) level. What should the nurse assess the client for?

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?