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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?

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.

Answer and Explanation

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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A. Withdraw the NGT and reinsert. B. Send fluid specimen to the laboratory. C. Connect the NGT to wall suction. D. Determine pH value of specimen.

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.

A. Ensure the client knows to stop baclofen before using other antispasmodics. B. Monitor intake and output every 8 hours. C. Advise the client to move slowly and cautiously when rising and walking. D. Evaluate muscle strength every 4 hours.

Correct Answer is C

Explanation

Rationale:

A. Baclofen should not be stopped abruptly as it can cause withdrawal symptoms. The client should consult their healthcare provider before using other antispasmodic.

B. Monitoring intake and output every 8 hours is not specific to baclofen administration.

C. Baclofen can cause dizziness, drowsiness, and hypotension. Advising the client to move slowly and cautiously when rising and walking helps prevent falls or injury due to these side effects.

D. While muscle strength assessment is important, it is not required every 4 hours and does not specifically address the common side effects of baclofen.

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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?

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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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?