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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 B

Explanation

Nitrofurantoin is an antibiotic commonly used to treat urinary tract infections. One of the adverse eﬀects of nitrofurantoin is diarrhea, which may be severe and watery. Therefore, it is important for the home care nurse to inform the client that the diarrhea may be a side eﬀect of the medication and requires further evaluation. The nurse should instruct the client to stop taking the medication and contact their healthcare provider for further assessment and treatment. The nurse should also assess the client's ﬂuid and electrolyte status and monitor for signs of dehydration.

Option a is important to consider, but it does not address the potential adverse eﬀect of the medication.

Option c may be appropriate in some cases, but it is not the priority intervention at this time.

Option d is not necessarily true and may cause unnecessary alarm to the client.

A. Advise the client to stop taking the drug and contact the healthcare provider. B. Ask the client to describe her dietary intake history for the last several days. C. Instruct the to increase her intake of saturated fats over the next week. D. Obtain a stool to evaluate occult blood and fat content. E. Obtain a stool to evaluate occult blood and fat content.

Correct Answer is B

Explanation

Orlistat works by inhibiting the absorption of dietary fat in the intestines. The side eﬀects of faty stools and ﬂatus can be managed by reducing the intake of dietary fat. The nurse should ask the client to describe her dietary intake history for the last several days to determine if she has been consuming a diet high in fat.

Based on this information, the nurse can provide appropriate dietary advice to help manage these side eﬀects.

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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

Two months after taking nitrofurantoin for a bacterial infection, a client reports the onset of severe, watery diarrhea to the home care nurse. How should the nurse respond?

Correct Answer is B

Explanation

After taking orlistat for one week, a female client tells the home health nurse that she is experiencing increasingly frequent faty stools and ﬂatus. Which action should the nurse take?

Correct Answer is B

Explanation

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