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: Tetracycline HCl can make the skin more sensitive to sunlight and increase the risk of sunburn. Therefore, the client should avoid exposure to direct sunlight and use sunscreen or protective clothing while taking the drug.

Choice B reason: Orange juice is acidic and can decrease the absorption of tetracycline HCl in the GI tract. Therefore, the client should not take the drug with orange juice or other acidic beverages.

Choice C reason: Serum drug levels are not routinely monitored for tetracycline HCl, as there is no established therapeutic range or toxicity level for this drug. Therefore, the client does not need to return to the clinic weekly to obtain serum drug levels.

Choice D reason: Milk and antacids can bind to tetracycline HCl and reduce its effectiveness. Therefore, the client should not take the drug with milk or antacids or within 2 hours of consuming them.

A. Hypertension. B. Bradycardia. C. Pupillary constriction. D. Scratchy throat.

Correct Answer is D

Explanation

Choice A reason: Hypertension is not a typical sign of an allergic reaction to piperacillin-tazobactam, which is an antibiotic. It may be caused by other factors, such as pain, anxiety, or renal impairment. The nurse should monitor the client's blood pressure and report any abnormal findings.

Choice B reason: Bradycardia is not a common or serious side effect of piperacillin-tazobactam. It may be related to other medications, such as beta-blockers, or underlying cardiac conditions. The nurse should check the client's pulse and rhythm and report any changes.

Choice C reason: Pupillary constriction is not associated with piperacillin-tazobactam or an allergic reaction. It may be caused by other drugs, such as opioids, or neurological disorders. The nurse should assess the client's level of consciousness and pupillary response.

Choice D reason: Scratchy throat is a possible sign of anaphylaxis, which is a severe and potentially fatal allergic reaction to piperacillin-tazobactam or any other drug. Other symptoms may include hives, swelling, wheezing, or hypotension. The nurse should stop the infusion immediately and call for help.

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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

The healthcare provider prescribes the antibiotic tetracycline HCl for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

Correct Answer is A

Explanation

The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?

Correct Answer is D

Explanation

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