an elderly female client comes to the clinic for a regular check up the client tells the nurse that she has increased her daily doses of acetaminophen

ATI LPN

ATI Adult Medical Surgical

1. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report?

A. Look at last quarter's hemoglobin and hematocrit to assess for dehydration.
B. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage.
C. Expect to find an increase in today's APTT compared to last quarter's due to bleeding.
D. Determine if there is a decrease in serum potassium due to renal compromise.

Correct answer: B

Rationale: When a client increases their daily doses of acetaminophen for joint pain, it raises concerns about possible liver damage due to acetaminophen overdose. LDH (Lactate Dehydrogenase) levels can indicate liver function, so comparing today's levels with previous ones can help assess for liver damage caused by acetaminophen overuse.

2. What is the primary cause of jaundice in a client with liver cirrhosis?

A. Decreased bile production
B. Increased bilirubin levels
C. Hepatic inflammation
D. Portal hypertension

Correct answer: B

Rationale: Jaundice in a client with liver cirrhosis is primarily caused by increased bilirubin levels. In liver cirrhosis, impaired liver function leads to the accumulation of bilirubin in the blood, resulting in jaundice. Bilirubin is a yellow pigment produced from the breakdown of red blood cells, and its elevation is a common manifestation of liver dysfunction. Choices A, C, and D are incorrect. While decreased bile production can contribute to jaundice, in liver cirrhosis, the key factor is the buildup of bilirubin due to liver dysfunction, not a decrease in bile production. Hepatic inflammation and portal hypertension are associated with liver cirrhosis but are not the primary causes of jaundice in this context.

3. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?

A. 4+ pitting edema of both lower extremities.
B. A Braden risk assessment scale rating score of ten.
C. Warm, dry skin with a fever of 100Â° F.
D. Hypoactive bowel sounds with infrequent bowel movements.

Correct answer: B

Rationale: A low Braden score indicates a high risk for pressure ulcers, making regular turning crucial to prevent skin breakdown.

4. What should the nurse include in patient teaching for a patient prescribed ceftriaxone for bacterial pneumonia?

A. Take the medication as prescribed.
B. Expect urine color changes.
C. Complete the full course of the antibiotic.
D. Avoid dairy products during treatment.

Correct answer: C

Rationale: When educating a patient prescribed ceftriaxone for bacterial pneumonia, it is crucial to emphasize completing the full course of the antibiotic. Completing the full course helps ensure the infection is completely eradicated and reduces the risk of antibiotic resistance. Incomplete courses of antibiotics can lead to treatment failure and the development of resistant bacterial strains. Therefore, it is essential for patients to adhere to the prescribed treatment regimen to achieve optimal outcomes.

5. A patient with epilepsy is prescribed phenytoin. What is the primary side effect the nurse should monitor for?

A. Hypotension
B. Gingival hyperplasia
C. Bradycardia
D. Hyperkalemia

Correct answer: B

Rationale: Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin. Patients should maintain good oral hygiene to minimize this effect.