A client taking atorvastatin develops an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

Peripheral edema.

Muscle tenderness.

Nausea and vomiting.

Excessive bruising.

Answer and Explanation

The Correct Answer is B

Choice A reason: Peripheral edema is not a common side effect of atorvastatin, and it is not related to increased CK levels. CK is an enzyme that is released when muscle tissue is damaged. Peripheral edema is more likely to be caused by heart failure, kidney disease, or venous insufficiency.

Choice B reason: Muscle tenderness is a sign of myopathy, which is a rare but serious adverse effect of atorvastatin. Myopathy is a condition where muscle fibers are damaged and inflamed, leading to muscle weakness and pain. Increased CK levels indicate muscle injury and can be a marker of myopathy. The nurse should monitor the client for muscle symptoms and report them to the prescriber.

Choice C reason: Nausea and vomiting are common gastrointestinal side effects of atorvastatin, but they are not associated with increased CK levels. Nausea and vomiting can be managed by taking the medication with food or reducing the dose.

Choice D reason: Excessive bruising is not a typical side effect of atorvastatin, and it is not linked to increased CK levels. Excessive bruising can be caused by bleeding disorders, anticoagulant therapy, or trauma. The nurse should assess the client for other signs of bleeding, such as hematuria, hematemesis, or melena.

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Correct Answer is D

Explanation

Choice A reason: Telling the client to notify the nurse if the pain is not relieved is an important nursing action, but it is not the highest priority. The nurse should assess the client's pain level before and after administering the medication, and evaluate its effectiveness. If the pain is not relieved, the nurse should report it to the prescriber and consider other interventions.

Choice B reason: Advising the client that the medication should start to work in about 30 minutes is an informative nursing action, but it is not the highest priority. The nurse should educate the client about the expected onset, peak, and duration of action of the medication, and how to take it safely and effectively. However, this does not address any immediate risks or needs of the client.

Choice C reason: Administering a stool softener/laxative at the same time as the analgesic is a preventive nursing action, but it is not the highest priority. The nurse should anticipate and prevent potential side effects of the medication, such as constipation, which can be caused by codeine. However, this does not address any urgent or emergent issues of the client.

Choice D reason: Instructing the client to request assistance when ambulating to the bathroom is the highest priority nursing action, as it addresses a serious safety concern of the client. The nurse should protect the client from falls and injuries, which can be caused by codeine's sedative and drowsy effects. The nurse should also monitor the client's respiratory rate and level of consciousness, as codeine can cause respiratory depression and altered mental status.

A. Prepare to assist with chest tube insertion. B. Initiate cardiopulmonary resuscitation (CPR). C. Determine Glasgow Coma Scale score. D. Administer a second dose of naloxone.

Correct Answer is D

Explanation

Choice A reason: Chest tube insertion is not indicated for respiratory depression caused by opioid overdose. It is a procedure used to treat pneumothorax, hemothorax, or pleural effusion.

Choice B reason: CPR is not the first-line intervention for respiratory depression. It is only indicated when the client has no pulse or signs of life.

Choice C reason: Glasgow Coma Scale score is a tool to assess the level of consciousness of a client. It is not an intervention that can reverse respiratory depression.

Choice D reason: Naloxone is an opioid antagonist that can reverse the effects of opioid overdose. It has a short half-life and may need to be repeated if the client's condition does not improve or worsens.

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A client taking atorvastatin develops an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action has the highest priority when administering a dose of codeine with acetaminophen to a client?

Correct Answer is D

Explanation

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

Correct Answer is D

Explanation

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