Which nursing action has the highest priority when administering a dose of codeine with acetaminophen to a client?
Tell the client to notify the nurse if the pain is not relieved.
Advise 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.
The Correct Answer is D
Choice A reason: Telling the client to notify the nurse if the pain is not relieved is an important nursing action, but it is not the highest priority. The nurse should assess the client's pain level before and after administering the medication, and evaluate its effectiveness. If the pain is not relieved, the nurse should report it to the prescriber and consider other interventions.
Choice B reason: Advising the client that the medication should start to work in about 30 minutes is an informative nursing action, but it is not the highest priority. The nurse should educate the client about the expected onset, peak, and duration of action of the medication, and how to take it safely and effectively. However, this does not address any immediate risks or needs of the client.
Choice C reason: Administering a stool softener/laxative at the same time as the analgesic is a preventive nursing action, but it is not the highest priority. The nurse should anticipate and prevent potential side effects of the medication, such as constipation, which can be caused by codeine. However, this does not address any urgent or emergent issues of the client.
Choice D reason: Instructing the client to request assistance when ambulating to the bathroom is the highest priority nursing action, as it addresses a serious safety concern of the client. The nurse should protect the client from falls and injuries, which can be caused by codeine's sedative and drowsy effects. The nurse should also monitor the client's respiratory rate and level of consciousness, as codeine can cause respiratory depression and altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.1"]
Explanation
To find out how many mL of dalteparin are needed for 2500 units, we need to use a proportion formula:
- (units of dalteparin)/(mL of dalteparin) = (units of dalteparin prescribed)/(mL of dalteparin needed)
- We can plug in the values that we know into the formula:
- (5000 units)/(0.2 mL) = (2500 units)/(x mL)
- We can cross-multiply and solve for x:
- 5000x = 2500 x 0.2
- x = (2500 x 0.2)/5000
- x = 0.1
- Therefore, the nurse should administer 0.1 mL of dalteparin to deliver 2500 units of the medication.
Correct Answer is D
Explanation
Choice A reason: Breast feeding is not recommended while taking this medication, as isotretinoin can pass into breast milk and harm
the nursing infant. However, this information is not as important as choice d, as the client may not be breast feeding or planning to breast feed.
Choice B reason: Baseline liver function results must be obtained during therapy, as isotretinoin can cause liver damage and increase liver enzymes. However, this information is not as important as choice d, as the client may not have liver problems or need liver function tests.
Choice C reason: Do not take multiple vitamins that contain vitamin A while taking this drug, as isotretinoin is a derivative of vitamin A and can cause vitamin A toxicity if taken in excess. However, this information is not as important as choice d, as the client may not take multiple vitamins or have vitamin A toxicity.
Choice D reason: Discontinue this medication one month before attempting to conceive, as isotretinoin can cause severe birth defects and miscarriages if taken during pregnancy. Therefore, this information is most important for the nurse to provide this client, as the client is planning to become pregnant and should avoid isotretinoin exposure.
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