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 A

Explanation

Choice A rationale

Vancomycin is known to potentially cause nephrotoxicity, which can lead to acute kidney injury.

Choice B rationale

Sucralfate is not typically associated with acute kidney injury.

Choice C rationale

Lorazepam is not typically associated with acute kidney injury.

Choice D rationale

While digoxin can have many side effects, it’s not typically associated with acute kidney injury.

A. Stool color and character. B. Fingerstick glucose. C. Serum electrolytes and ammonia. D. Serum hepatic enzymes.

Correct Answer is C

Explanation

Choice A rationale

While changes in stool color and character can be indicative of various health conditions, they are not the best indicators of a patient’s therapeutic response to lactulose in the context of hepatic encephalopathy.

Choice B rationale

Fingerstick glucose monitoring is important in managing conditions like diabetes, but it does not provide the best information to evaluate a patient’s therapeutic response to lactulose in the context of hepatic encephalopathy.

Choice C rationale

Lactulose is used in the management of hepatic encephalopathy, a condition that can occur in patients with severe liver disease. It works by reducing the absorption of ammonia in the gut, which is a toxin that can accumulate in the blood in patients with liver dysfunction. Therefore, monitoring serum electrolytes and ammonia levels can help evaluate the effectiveness of lactulose therapy.

Choice D rationale

While monitoring serum hepatic enzymes can provide valuable information about liver function, it does not provide the best information to evaluate a patient’s therapeutic response to lactulose in the context of hepatic encephalopathy.

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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

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

Correct Answer is A

Explanation

A patient with hepatic encephalopathy is receiving lactulose.Which assessment provides the nurse with the best information to evaluate the patient’s therapeutic response to the drug?

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?