Which nursing action has the highest priority when administering a dose of codeine with acetaminophen to a client?
Instruct the client to request assistance when ambulating to the bathroom.
Administer a stool softener/laxative at the same time as the analgesic.
Advise the client that the medication should start to work in about 30 minutes.
Tell the client to notify the nurse if the pain is not relieved.
The Correct Answer is A
Choice A reason: This is the highest priority action for the nurse to take. Codeine is an opioid analgesic that can cause drowsiness, dizziness, and impaired coordination. These effects can increase the risk of falls and injuries in the client, especially when ambulating to the bathroom. The nurse should instruct the client to request assistance when getting out of bed or walking, and provide adequate support and supervision.
Choice B reason: This is not the highest priority action for the nurse to take. Administering a stool softener/laxative at the same time as the analgesic is a preventive measure that can help reduce the risk of constipation, which is a common side effect of codeine. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.
Choice C reason: This is not the highest priority action for the nurse to take. Advising the client that the medication should start to work in about 30 minutes is an informative and reassuring measure that can help the client cope with pain and anxiety. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.
Choice D reason: This is not the highest priority action for the nurse to take. Telling the client to notify the nurse if the pain is not relieved is an evaluative and responsive measure that can help the nurse monitor the effectiveness of the analgesic and adjust the dosage or frequency as needed. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured after the completion of the IV dose, not during the administration. The trough level should be measured just before the next administration, not 30 minutes before.
Choice B reason: This is the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, when the concentration of the medication is highest in the blood. The trough level should be measured one hour before the next administration, when the concentration of the medication is lowest in the blood.
Choice C reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not two hours after. The trough level should be measured one hour before the next administration, not two hours before.
Choice D reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not immediately after. The trough level should be measured one hour before the next administration, not 30 minutes before.
Correct Answer is A
Explanation
Choice A reason: This is the most significant information about this finding. St. John's Wort is an herbal supplement that is used for various conditions, such as depression, anxiety, or insomnia. However, it can also interact with many medications, including cyclosporine, which is an immunosuppressant drug that is used to prevent organ rejection after transplantation. St. John's Wort can induce the activity of certain enzymes in the liver that metabolize cyclosporine, leading to lower levels of the drug in the blood and reduced efficacy. This can increase the risk of graft rejection and complications. The nurse should inform the healthcare provider and educate the client about the potential interaction and the importance of avoiding St. John's Wort and other herbal products without consulting the provider.
Choice B reason: This is not significant information about this finding. Adding the herb can not decrease the need for corticosteroids, which are another type of immunosuppressant drug that are used to prevent organ rejection after transplantation. St. John's Wort does not have any anti-inflammatory or immunomodulatory effects that can reduce the dosage or frequency of corticosteroids. On the contrary, it can interfere with the metabolism and absorption of corticosteroids, as well as other medications, and cause adverse effects or reduced efficacy. The nurse should advise the client to follow the prescribed regimen of corticosteroids and other drugs, and not to self-medicate with herbal products.
Choice C reason: This is not significant information about this finding. The client probably used this herb to treat depression, which is a common condition among transplant recipients, due to the stress, anxiety, and lifestyle changes associated with the procedure. However, this does not explain the cause of the graft rejection, nor does it justify the use of St. John's Wort without consulting the healthcare provider. St. John's Wort is not a proven or safe treatment for depression, and it can interact with many antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs), and cause serious side effects, such as serotonin syndrome. The nurse should assess the client's mental health status and refer the client to a mental health professional if needed.
Choice D reason: This is not a significant information about this finding. Ingestion of St. John's Wort can not reduce the client's intake of sodium, which is an electrolyte that is essential for the fluid balance and nerve function in the body. St. John's Wort does not have any diuretic or sodium-lowering effects that can affect the sodium levels in the blood or urine. The nurse should monitor the client's sodium levels and fluid intake and output, and report any abnormal findings to the healthcare provider. The nurse should also teach the client about the dietary sources and recommendations of sodium, and the signs and symptoms of hyponatremia or hypernatremia.
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