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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the best option to measure the peak and trough levels of vancomycin, as it reflects the highest and lowest concentrations of the drug in the blood. The peak level indicates the efficacy and potential toxicity of vancomycin, while the trough level indicates the clearance and potential subtherapeutic effect of vancomycin. The peak level should be drawn immediately after completion of the IV dose, as it takes about 30 minutes for vancomycin to reach its maximum concentration in the blood. The trough level should be drawn 30 minutes before the next administration of the medication, as it represents the lowest concentration of vancomycin in the blood before it is replenished by another dose.

Choice B reason: This is not a good option to measure the peak and trough levels of vancomycin, as it may not capture the true highest and lowest concentrations of the drug in the blood. The peak level may be lower than expected, as it takes about 30 minutes for vancomycin to reach its maximum concentration in the blood. The trough level may be higher than expected, as it is drawn too close to the next administration of the medication.

Choice C reason: This is not a good option to measure the peak and trough levels of vancomycin, as it does not reflect the highest and lowest concentrations of the drug in the blood. The peak level is drawn too early, as vancomycin has not reached its maximum concentration in the blood yet. The trough level is drawn too late, as vancomycin has already started to decline in the blood.

Choice D reason: This is not a good option to measure the peak and trough levels of vancomycin, as it may miss the highest and lowest concentrations of the drug in the blood. The peak level is drawn too late, as vancomycin may have already started to decline in the blood. The trough level is drawn too early, as vancomycin may have not reached its minimum concentration in the blood yet.

A. Implement neutropenic precautions. B. Inform the client that the medication has been effective. C. Review the client's culture and sensitivity reports. D. Assess the client's vital signs.

Correct Answer is B

Explanation

Choice A reason: Neutropenic precautions are necessary when the WBC count is critically low, typically below the normal range. Since the client’s WBC count is now within the normal range, these precautions are no longer required.

Choice B reason: Filgrastim is designed to increase white blood cell (WBC) production in individuals with neutropenia. In this case, the client’s WBC count has increased from 2,500/mm³ (2.5 x 10⁹/L) to 5,000/mm³ (5 x 10⁹/L), reaching the lower limit of the normal reference range (5,000 to 10,000/mm³ or 5 to 10 x 10⁹/L). This indicates that the medication has achieved its desired effect, and it is appropriate to inform the client of this positive outcome.

Choice C reason:reason: Reviewing culture and sensitivity reports would be relevant if there was evidence of infection or a need to evaluate ongoing treatment for an infection. This is not indicated by the scenario provided.

Choice D reason: While assessing vital signs is generally important, there is no indication in this scenario that an acute issue requiring immediate vital sign monitoring is present.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving intravenous (IV) vancomycin and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times provide the best determination of these levels?

Correct Answer is A

Explanation

After receiving five doses of filgrastim, the nurse notes that the client's white blood cell count has increased from 2,500/mm3 (2.5 x 109/L) to 5,000/mm3 (5 x 109/L). Which action should the nurse implement? White Blood Cell (WBC) [Reference Range: 5000 to 10,000/mm3 (5 to 10 x 109/L)]

Correct Answer is B

Explanation

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