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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?

A.

Use a pulse oximeter to assess oxygen saturation.

B.

Advise the client to reduce the medication dose.

C.

Report the finding to the healthcare provider.

D.

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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View Related questions

Correct Answer is B

Explanation

Rationale:

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.

B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.

C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.

D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

Correct Answer is B

Explanation

Rationale:

A. Rubber-soled slippers do not provide adequate support or stability for a client with weakness.

B. Tennis shoes with velcro offer good support, stability, and ease of use, which is important for clients with weakness or impaired mobility.

C. Leather-soled loafers may be slippery and do not provide as much support or stability.

D. Slip-on rubber shower shoes lack adequate support and can be unsafe for ambulation.

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