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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Insulin glargine is a long-acting insulin that is given once daily at the same time every day via subcutaneous injection. Therefore, it is essential to teach the client self-injection skills for daily subcutaneous administration to ensure proper administration of insulin.
Option b is incorrect because insulin glargine is typically given at the same dose every day, not based on before meal blood sugar readings.
Option c is incorrect because insulin glargine is not used for the treatment of severe hypoglycemia, and it should not be administered by someone who is not trained to do so.
Option d is incorrect because ketoacidosis is a serious complication of diabetes mellitus that requires urgent medical atention, and increasing medication dosage is not appropriate for this condition.
Correct Answer is D
Explanation
Diclofenac, like other NSAIDs, can cause gastrointestinal irritation and bleeding. The client’s symptoms of pallor and fatigue may indicate anemia due to blood loss. Reviewing the client’s hemoglobin level would help the nurse determine if the client is experiencing anemia and if further evaluation and intervention are needed.
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