Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. Check the client's capillary glucose level.
Checking the capillary glucose level is not relevant to the observation of yellow skin color. Jaundice is related to liver function, not glucose levels.
B. Use a pulse oximeter to assess oxygen saturation.
Oxygen saturation measurement is not relevant to the observation of yellow skin color. It is used to assess the oxygen-carrying capacity of the blood, not liver function.
C. Report the finding to the healthcare provider.
Yellow discoloration of the skin (jaundice) can be indicative of liver dysfunction or damage. Since the client takes acetaminophen for chronic pain, which is metabolized in the liver, the nurse should be concerned about potential hepatotoxicity. Reporting the findings to the healthcare provider is essential for further evaluation and management.
D. Advise the client to reduce the medication dose.
Reducing the medication dose is not appropriate without further evaluation and guidance from the healthcare provider. Jaundice may indicate liver dysfunction, and altering the medication without professional assessment could be unsafe.
This question is an excerpt from Nurse Dive's nursing test bank - Hesi Pharmacology Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale: Checking the capillary glucose level is not relevant to the observation of yellow skin color. Jaundice is related to liver function, not glucose levels.
Choice B rationale: Oxygen saturation measurement is not relevant to the observation of yellow skin color. It is used to assess the oxygen-carrying capacity of the blood, not liver function.
Choice C rationale: Yellow discoloration of the skin (jaundice) can be indicative of liver dysfunction or damage. Since the client takes acetaminophen for chronic pain, which is metabolized in the liver, the nurse should be concerned about potential hepatotoxicity. Reporting the findings to the healthcare provider is essential for further evaluation and management.
Choice D rationale: Reducing the medication dose is not appropriate without further evaluation and guidance from the healthcare provider. Jaundice may indicate liver dysfunction, and altering the medication without professional assessment could be unsafe.
Similar Questions
The nurse is administering sodium polystyrene sulfonate to a client in acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?
- Glucose [Reference Range: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
- Hemoglobin (Hgb) [Reference Range:12-16 g/dL (120-160 g/L)]
- Potassium (K+) [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
- Ammonia [Reference Range: Adult: 10 to 80 Mcg/dL (6 to 47 Mcmol/dL)]
A. Serum ammonia level of 30 Mcg/dL (17.62 Mcmol /dL).
Serum ammonia levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
B. Serum potassium level of 3.8 mEq/L (3.8 mmol/L).
Sodium polystyrene sulfonate is a medication used to treat hyperkalemia (high potassium levels). A serum potassium level of 3.8 mEq/L falls within the normal reference range (3.5 to 5.0 mEq/L), indicating that the medication has been effective in promoting the excretion of potassium and reducing hyperkalemia.
C. Serum glucose level of 120 mg/dL (6.7 mmol/L).
Serum glucose levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
D. Hemoglobin level of 13.5 g/dL (135 g/L).
Hemoglobin levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
Full Explanation
Choice A rationale: Serum ammonia levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
Choice B rationale: Sodium polystyrene sulfonate is a medication used to treat hyperkalemia (high potassium levels). A serum potassium level of 3.8 mEq/L falls within the normal reference range (3.5 to 5.0 mEq/L), indicating that the medication has been effective in promoting the excretion of potassium and reducing hyperkalemia.
Choice C rationale: Serum glucose levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
Choice D rationale: Hemoglobin levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
The nurse is caring for a client who has been taking ibuprofen. Which finding is most important for the nurse report to the healthcare provider?
A. Hematemesis.
Hematemesis refers to the vomiting of blood and is a severe and potentially life-threatening adverse effect of ibuprofen. Ibuprofen belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal bleeding and ulcerations. Hematemesis indicates significant gastrointestinal irritation or bleeding, and it requires immediate attention from the healthcare provider to assess and manage the client's condition.
B. Nausea.
Nausea is a common side effect of ibuprofen and other NSAIDs. While it is important to monitor and address any adverse effects experienced by the client, nausea alone is not as urgent or critical as hematemesis, which can indicate a more severe complication.
C. Insomnia.
Insomnia is not directly related to the use of ibuprofen. While sleep disturbances can occur as a side effect of some medications, it is not the most important finding to report to the healthcare provider in this context.
D. Dizziness.
Dizziness can be a side effect of ibuprofen, but it is not the most concerning finding in this situation. Hematemesis, which indicates potential gastrointestinal bleeding, is a more critical symptom that requires immediate attention and reporting to the healthcare provider.
Full Explanation
Choice A rationale: Hematemesis refers to the vomiting of blood and is a severe and potentially life-threatening adverse effect of ibuprofen. Ibuprofen belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal bleeding and ulcerations.
Hematemesis indicates significant gastrointestinal irritation or bleeding, and it requires immediate attention from the healthcare provider to assess and manage the client's condition.
Choice B rationale: Nausea is a common side effect of ibuprofen and other NSAIDs. While it is important to monitor and address any adverse effects experienced by the client, nausea alone is not as urgent or critical as hematemesis, which can indicate a more severe complication.
Choice C rationale: Insomnia is not directly related to the use of ibuprofen. While sleep disturbances can occur as a side effect of some medications, it is not the most important finding to report to the healthcare provider in this context.
Choice D rationale: Dizziness can be a side effect of ibuprofen, but it is not the most concerning finding in this situation. Hematemesis, which indicates potential gastrointestinal bleeding, is a more critical symptom that requires immediate attention and reporting to the healthcare provider.
After taking orlistat for one week, a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. Which action should the nurse take?
A. Instruct the client to increase her intake of saturated fats over the next week.
This option is not appropriate as increasing saturated fat intake would exacerbate the oily stool and flatus symptoms caused by orlistat. Orlistat is specifically designed to reduce fat absorption, and increasing fat intake would be counterproductive and may worsen the side effects.
B. Ask the client to describe her dietary intake history for the last several days.
While it is important to assess the client's dietary intake history, it may not provide specific insights into the cause of the oily stools and flatus. These symptoms are well- known side effects of orlistat, and it is not necessary to gather dietary history information to confirm this. Instead, the focus should be on addressing the side effects and discussing the continuation of the medication with the healthcare provider.
C. Advise the client to stop taking the drug and contact her healthcare provider.
The client is experiencing increasingly frequent oily stools and flatus, which are common side effects of orlistat. Orlistat is a medication used to aid weight loss by inhibiting the absorption of dietary fats in the intestines. By blocking the enzyme responsible for breaking down fats, orlistat prevents the absorption of a portion of the dietary fat, leading to increased fat content in the stool.
D. Obtain a stool specimen to evaluate for occult blood and fat content.
While obtaining a stool specimen for evaluation might be relevant in some situations, it is not the priority in this case. The oily stools and flatus are most likely related to the side effects of orlistat and do not typically require stool testing for confirmation. The more immediate action would be to address the symptoms by advising the client to stop taking the medication and contact her healthcare provider for further guidance.
Full Explanation
Choice A rationale: This option is not appropriate as increasing saturated fat intake would exacerbate the oily stool and flatus symptoms caused by orlistat. Orlistat is specifically designed to reduce fat absorption, and increasing fat intake would be counterproductive and may worsen the side effects.
Choice B rationale: Asking a client to describe their dietary intake history is a standard practice in nutritional assessment. It provides a baseline for understanding current eating habits and identifying areas for improvement.
Choice C rationale: Advising a client to stop taking medication should only be done by a qualified healthcare provider who has full knowledge of the client's health history and current medications.
Choice D rationale: While obtaining a stool specimen for evaluation might be relevant in some situations, it is not the priority in this case. The oily stools and flatus are most likely related to the side effects of orlistat and do not typically require stool testing for confirmation. The more immediate action would be to address the symptoms by advising the client to stop taking the medication and contact her healthcare provider for further guidance.