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 B
Explanation
Rationale:
A. Pulse volume and bruit are different assessments; pulse volume is not graded in the context of auscultation findings.
B. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, often due to stenosis or narrowing. Documenting a "left carotid artery bruit present" accurately reflects the findings.
C. The presence of a bruit does not necessarily mean the pulse is strong or that there is occlusion.
D. A bruit indicates turbulent flow, not necessarily complete occlusion.
Correct Answer is B
Explanation
Rationale:
A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.
B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.
C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.
D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.