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

Advice the client that the medication should start to work in about 30 minutes.

Administer a stool softener/laxative at the same time as the analgesic.

Instruct the client to request assistance when ambulating to the bathroom.

Tell the client to notify the nurse if the pain is not relieved.

Answer and Explanation

The Correct Answer is C

The correct answer is C. Instruct the client to request assistance when ambulating to the bathroom.

Choice A reason:

Advise the client that the medication should start to work in about 30 minutes.

While it is important to inform the client about the onset of action of the medication, this is not the highest priority. Codeine, an opioid, can cause dizziness and sedation, which increases the risk of falls. Therefore, safety measures take precedence over informing the client about the medication’s onset time.

Choice B reason:

Administer a stool softener/laxative at the same time as the analgesic.

Opioids like codeine can cause constipation, so administering a stool softener or laxative is a good practice. However, this action is not the highest priority when considering the immediate safety of the client. Ensuring the client’s safety from potential falls due to dizziness or sedation is more urgent.

Choice C reason:

Instruct the client to request assistance when ambulating to the bathroom.

This is the correct answer because codeine can cause dizziness, sedation, and orthostatic hypotension, increasing the risk of falls. Ensuring the client requests assistance when moving can prevent potential injuries, making it the highest priority nursing action.

Choice D reason:

Tell the client to notify the nurse if the pain is not relieved.

While it is important for the client to communicate about the effectiveness of pain relief, this is not the highest priority. The immediate concern is the client’s safety due to the sedative effects of codeine. Therefore, preventing falls and injuries takes precedence.

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Correct Answer is D

Explanation

A carbamazepine level of 8.4 mg/L is within the therapeutic range of 4-12 mg/L. The nurse should administer the evening dose of carbamazepine as prescribed. The nurse should continue to monitor the client’s carbamazepine levels and assess for any side eﬀects of the medication.

A. Administers onto the ﬂeshy outer thigh. B. Inserts the injection pen through clothing. C. Holding the pen in place for several seconds after injection D. Cleans the injector pen for re-use. E. None F. None

Correct Answer is D

Explanation

A. Administers onto the ﬂeshy outer thigh: This is the recommended site for epinephrine auto-injection because it allows for quick absorption into the bloodstream. The outer thigh is a large muscle area, which helps in the rapid distribution of the medication.

B. Inserts the injection pen through clothing: It is generally acceptable to inject epinephrine through clothing in an emergency situation. This practice ensures that there is no delay in administering the life-saving medication, which is crucial during an anaphylactic reaction.

C. Cleanses the injection pen for re-use: Epinephrine auto-injectors are designed for single use only. Reusing the pen can lead to contamination and reduced effectiveness of the medication. It is important to dispose of the used injector properly and obtain a new one for future use.

D. Holds the pen in place after injection: Holding the pen in place for a few seconds after injection ensures that the full dose of medication is delivered. This practice helps in maximizing the effectiveness of the treatment during an anaphylactic emergency.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to administering the evening dose of carbamazepine, the nurse noted that the client’s morning carbamazepine level was 8.4 mg/L. Which action should the nurse take?

Correct Answer is D

Explanation

The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen. Which client action requires intervention by the nurse?

Correct Answer is D

Explanation

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

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