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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 C

Explanation

Oxybutynin is a medicine used to treat symptoms of an overactive bladder. One of the side eﬀects of oxybutynin is that it can cause dry mouth, constipation, and dry skin21. These side eﬀects can increase the risk of dehydration. Additionally, oxybutynin can cause ﬂushing and heat stroke. Therefore, it is important for the client to take measures to avoid dehydration and over-heating while training for a marathon.

A. Explain that the drug should be used early in the course of the disease process. B. Affirm the decision to use the drug when the symptoms start to worsen. C. Assess the client’s current mental health status before deciding to support the decision. D. Confirm that the daughter is aware of the progressive nature of the disease.

Correct Answer is A

Explanation

The nurse should explain to the client's daughter that Rivastigmine is most eﬀective when used early during Alzheimer's disease. Delaying the use of the medication until the symptoms are no longer manageable may result in the drug being less eﬀective.

The nurse should emphasize the importance of following the healthcare provider's instructions for administering the medication to maximize its therapeutic eﬀect. It is important to educate the client's daughter about the progressive nature of Alzheimer's disease and the need for ongoing monitoring and care.

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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

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a marathon. Which instruction should the nurse emphasize?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

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The nurse is planning to administer the antiulcer GI agent sucralfate to a client with a peptic ulcer disease. Which action should the nurse include in this client’s plan of care?

The nurse is planning to discharge teaching for a client with diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse include in the discharge teaching?

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

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