The nurse is providing care for a client who is taking acetaminophen (Tylenol). What should the nurse pay particular attention to during the assessment?
1. Respiratory rate
2. Pulse rate
3. Blood pressure
4. Severe upper or lower abdominal pain
Correct Answer: 4
Rationale 1: Acetaminophen does not change respiratory rate.
Rationale 2: Acetaminophen does not change pulse.
Rationale 3: Acetaminophen does not change blood pressure.
Rationale 4: Clients on acetaminophen (Tylenol) should report signs of liver toxicity, nausea, vomiting, anorexia, bleeding, severe upper or lower abdominal pain, heartburn, jaundice, or a change in the color or character of stools.
Global Rationale: Clients on acetaminophen (Tylenol) should report signs of liver toxicity, nausea, vomiting, anorexia, bleeding, severe upper or lower abdominal pain, heartburn, jaundice, or a change in the color or character of stools. Acetaminophen does not change respiratory rate. Acetaminophen does not change pulse. Acetaminophen does not change blood pressure.
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