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 C

Explanation

Choice A rationale

Decreasing cigarette use to a pack per day is not enough. Smoking can increase stomach acid and reduce the ability of the stomach lining to resist acid, thus aggravating peptic ulcer disease. Therefore, the patient should be advised to quit smoking entirely.

Choice B rationale

Lethargy could be a side effect of cimetidine. It’s important for the patient to notify the healthcare provider if they experience this, as it could indicate a need to adjust the medication.

Choice C rationale

Cimetidine should be taken with or immediately following meals for best absorption. If antacids are used, they should be taken at least one hour apart from cimetidine. Therefore, taking the medication an hour after antacids is incorrect and indicates the need for further instruction.

Choice D rationale

Sexual dysfunction is a rare but possible side effect of cimetidine. Patients should be advised to monitor for this and report any issues to their healthcare provider.

A. Nausea and diarrhea can occur when using this supplement. B. Ginkgo biloba use should be limited and not taken during pregnancy. C. Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo. D. Anxiety and headaches increase with the use of ginkgo biloba.

Correct Answer is C

Explanation

Choice A rationale

While nausea and diarrhea can occur when using ginkgo biloba, these side effects are not the most important information for the nurse to include in the teaching plan for this client. These are common side effects that can occur with many medications and supplements, and while they should be mentioned, they are not the most critical concern with ginkgo biloba use.

Choice B rationale

The statement that ginkgo biloba use should be limited and not taken during pregnancy is important, but it is not the most critical information for this client. While ginkgo biloba should be used with caution during pregnancy, this information may not be relevant to this particular client unless she is pregnant or planning to become pregnant.

Choice C rationale

The interaction of ginkgo biloba with aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) is the most important information for the nurse to include in the teaching plan for this client. Ginkgo biloba can increase the risk of bleeding, especially when taken with other medications that affect blood clotting, such as aspirin and NSAIDs. This could lead to serious health complications for the client.

Choice D rationale

While anxiety and headaches can increase with the use of ginkgo biloba, these side effects are not the most important information for the nurse to include in the teaching plan for this client.

These are common side effects that can occur with many medications and supplements, and while they should be mentioned, they are not the most critical concern with ginkgo biloba use.

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

Correct Answer is C

Explanation

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba.What is the most important information for the nurse to include in the teaching plan for this client?

Correct Answer is C

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?