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?
Use a pulse oximeter to assess oxygen saturation.
Advise the client to reduce the medication dose.
Report the finding to the healthcare provider.
Check the client's capillary glucose level.
The Correct Answer is C
Rationale:
A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.
B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.
C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.
D. Checking capillary glucose levels is not relevant to the assessment of jaundice.
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Correct Answer is D
Explanation
Rationale:
A. Withdrawing and reinserting the NGT should only be done if the tube is misplaced or dislodged.
B. Sending the fluid to the lab is unnecessary unless there is a specific concern, such as infection.
C. Connecting the NGT to wall suction should only be done after confirming proper placement.
D. Determining the pH value of the aspirated fluid helps verify that the NGT is correctly positioned in the stomach. Gastric fluid typically has a pH of 1 to 5, confirming proper placement.
Correct Answer is D
Explanation
Rationale:
A. The presence of a supernumerary breast nipple is not related to the onset of menarche and is not a common assessment in determining sexual maturity.
B. Temporary gynecomastia is more commonly observed in adolescent boys rather than preteen girls.
C. While age can provide a rough estimate, it is not as accurate as a physical assessment of sexual maturity.
D. The Tanner staging is a reliable method used to assess sexual maturity in adolescents. It includes evaluating the development of breasts, pubic hair, and other secondary sexual characteristics, which can help determine if the client has likely reached menarche.