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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Rationale:
A. While additional sleep may be helpful, it does not address the root cause of the hangover effect from temazepam.
B. A benzodiazepine antagonist is typically used in cases of overdose, not for managing next-day drowsiness.
C. Temazepam is a benzodiazepine, and sudden discontinuation can lead to withdrawal symptoms. The nurse should advise the client to taper off the medication gradually under medical supervision to prevent withdrawal symptoms and minimize the "hangover" effect.
D. Stopping the medication abruptly can lead to withdrawal symptoms and is not recommended.
Correct Answer is C
Explanation
Rationale:
A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.
B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.
C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.
D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.