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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Performing a neurological exam is not the priority action in this situation. Confusion and blurred vision are signs of hypoglycemia, which is a low blood sugar level. Glipizide is a medication that lowers blood sugar by stimulating the pancreas to produce more insulin. The nurse should first confirm the blood sugar level before performing any other assessments or interventions.

Choice B reason: Obtaining a fingerstick blood glucose is the best action in this situation. This is a quick and easy way to measure the blood sugar level and determine if the client is experiencing hypoglycemia. The nurse should use a glucometer and a lancet to prick the client's finger and obtain a drop of blood. The nurse should compare the result with the normal range and follow the hypoglycemia protocol.

Choice C reason: Administering glucagon intramuscularly is not the first action in this situation. Glucagon is a hormone that raises blood sugar by stimulating the breakdown of glycogen in the liver. It is used as an emergency treatment for severe hypoglycemia, when the client is unconscious or unable to swallow. The nurse should only administer glucagon after confirming the blood sugar level and trying oral glucose first.

Choice D reason: Measuring the client's vital signs is not the priority action in this situation. Vital signs include blood pressure, pulse, respiration, and temperature. They can provide information about the client's overall health and stability, but they are not specific to hypoglycemia. The nurse should focus on the blood sugar level, which is the most relevant indicator of hypoglycemia.

A. Administer both prescribed medications as scheduled. B. Hold the calcium carbonate, but administer the calcitriol as scheduled. C. Hold both medications until contacting the healthcare provider. D. Hold the calcitriol, but administer the calcium carbonate as scheduled.

Correct Answer is C

Explanation

Choice A reason: Administering both prescribed medications as scheduled is not the appropriate action in this situation. The client's total calcium level is above the normal range of 9 to 10.5 mg/dL (2.25 to 2.62 mmol/L), indicating hypercalcemia. Hypercalcemia is a serious condition that can cause nausea, vomiting, constipation, confusion, kidney stones, and cardiac arrhythmias. Giving more calcitriol and calcium carbonate would worsen the client's condition and increase the risk of complications.

Choice B reason: Holding the calcium carbonate, but administering the calcitriol as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Calcitriol is a synthetic form of vitamin D that helps the body absorb calcium from the intestines and kidneys. Both medications can increase the blood calcium level and cause hypercalcemia. The nurse should not give either medication without consulting the healthcare provider.

Choice C reason: Holding both medications until contacting the healthcare provider is the best action in this situation. The nurse should recognize that the client's total calcium level is dangerously high and report it to the healthcare provider as soon as possible. The healthcare provider may order to stop or adjust the doses of calcitriol and calcium carbonate, and prescribe other treatments to lower the blood calcium level, such as intravenous fluids, diuretics, or bisphosphonates.

Choice D reason: Holding the calcitriol, but administering the calcium carbonate as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Giving more calcium carbonate to a client with hypercalcemia would increase the blood calcium level even more and cause more harm. The nurse should not give any medication that can raise the blood calcium level without consulting the healthcare provider.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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