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 D

Explanation

Choice A reason: Recent use of other antidepressants is important to know, as duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that can interact with other antidepressants, especially monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs). However, this information is not as important as liver function laboratory results, as duloxetine can cause hepatotoxicity in some clients.

Choice B reason: Weight change in the last month is relevant to monitor, as duloxetine can cause weight loss or gain in some clients. However, this information is not as important as liver function laboratory results, as duloxetine can cause liver damage in some clients.

Choice C reason: Family history of mental illness is useful to assess, as duloxetine may be more effective or less effective in clients with certain genetic factors. However, this information is not as important as liver function laboratory results, as duloxetine can cause liver failure in some clients.

Choice D reason: Liver function laboratory results are most important to obtain, as duloxetine is metabolized by the liver and can cause hepatotoxicity in some clients. The nurse should monitor the client's liver enzymes and bilirubin levels before and during treatment with duloxetine and report any signs of liver impairment, such as jaundice, dark urine, abdominal pain, or fatigue.

A. Hematemesis. B. Insomnia. C. Dizziness. D. Nausea.

Correct Answer is A

Explanation

Choice A reason: Hematemesis is the vomiting of blood, which can indicate a serious gastrointestinal bleeding caused by ibuprofen. This is a life-threatening condition that requires immediate medical attention. Therefore, the nurse should report this finding to the healthcare provider as soon as possible.

Choice B reason: Insomnia is the difficulty in falling asleep or staying asleep. It can be a side effect of ibuprofen, but it is not as serious or urgent as hematemesis. The nurse can advise the client to take ibuprofen with food or milk, avoid caffeine and alcohol, and practice good sleep hygiene.

Choice C reason: Dizziness is the feeling of lightheadedness, faintness, or unsteadiness. It can also be a side effect of ibuprofen, but it is usually mild and transient. The nurse can instruct the client to rise slowly from a sitting or lying position, drink plenty of fluids, and avoid driving or operating machinery if dizzy.

Choice D reason: Nausea is the feeling of discomfort or unease in the stomach that may lead to vomiting. It can also be a side effect of ibuprofen, but it is usually manageable with simple measures. The nurse can suggest the client to take ibuprofen with food or milk, eat small and frequent meals, and avoid spicy or fatty foods.

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

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