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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View Related questions
Correct Answer is A
Explanation
Rationale:
A. Acetaminophen, especially in high doses or with prolonged use, is known to cause hepatotoxicity, which can lead to jaundice. Notifying the healthcare provider is crucial to prevent further liver damage.
B. Captopril, an ACE inhibitor used for hypertension, is not commonly associated with jaundice or liver dysfunction.
C. Omeprazole, a proton pump inhibitor used for GERD, is less likely to cause liver damage compared to acetaminophen.
D. Prednisone, a corticosteroid, can have many side effects, but hepatotoxicity is not among the most common, making acetaminophen the most concerning drug in this context.
Correct Answer is D
Explanation
Rationale:
A. The clavicle is an important landmark but not the ideal starting point for auscultating breath sounds.
B. The sternum is also not the correct starting location for breath sound auscultation.
C. The aortic site is unrelated to lung auscultation.
D. The lung apex, located above the clavicle, is the correct location to begin auscultating anterior breath sounds. This systematic approach ensures all areas of the lungs are assessed for normal and abnormal breath sounds.