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. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.
Correct Answer is D
Explanation
Rationale:
A. Renal creatinine clearance is important in assessing kidney function but is not directly related to divalproex sodium therapy.
B. While CBC monitoring is essential, especially for detecting thrombocytopenia, liver function tests are more critical in this context.
C. A chemistry panel is valuable but does not specifically monitor for the primary risks associated with divalproex sodium.
D. Divalproex sodium (valproate) can cause hepatotoxicity, so monitoring liver function tests (LFTs) is crucial. Regular LFTs help detect early signs of liver damage, which can be a serious adverse effect of this medication.