A nurse is assessing a client receiving codeine for a persistent cough caused by upper respiratory infection. Which finding would require the nurse to intervene?
Client experiences respiratory depression.
Dry mouth persists throughout the day.
Client reports mild drowsiness after each dose.
Coughing partially improves but persists at night.
The Correct Answer is A
A. Client experiences respiratory depression: Codeine is an opioid agonist that suppresses the medullary cough center and can concurrently depress the respiratory drive. A significant reduction in respiratory rate or tidal volume indicates systemic toxicity and compromised gas exchange. This life-threatening adverse effect necessitates immediate clinical intervention.
B. Dry mouth persists throughout the day: Xerostomia is a common anticholinergic-like side effect associated with various opioid medications used for antitussive purposes. While uncomfortable for the patient, it does not represent an acute physiological threat or a failure of the therapeutic regimen. It is managed with oral hygiene.
C. Client reports mild drowsiness after each dose: Opioids cross the blood-brain barrier and exert sedative effects on the central nervous system. Mild somnolence is an expected pharmacological response and generally does not require intervention unless it progresses to an altered level of consciousness. It is a predictable side effect.
D. Coughing partially improves but persists at night: The therapeutic goal of codeine in an upper respiratory infection is the symptomatic relief of a non-productive cough. Partial improvement suggests the medication is reaching therapeutic levels but may not completely abolish the reflex. Persistent coughing is a clinical observation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encouraging increased fluid intake:Hydration is a core supportive measure for viral infections to maintain mucosal moisture and facilitate the clearance of debris. It prevents the complications of dehydration associated with fever or reduced oral intake. This is a highly appropriate and standard nursing intervention for viral pharyngitis.
B. Advising on rest and avoiding exertion:Conserving metabolic energy allows the body to prioritize the immunological response required to clear the viral load. Physical exertion can exacerbate fatigue and delay the recovery process. Rest is an essential component of the non-pharmacological management of viral upper respiratory infections.
C. Recommending throat lozenges for discomfort relief:Lozenges provide localized soothing and can temporarily reduce the severity of odynophagia. They act as a topical analgesic to improve the patient's comfort and ability to maintain oral hydration. This is an appropriate symptomatic treatment for the inflammation seen in pharyngitis.
D. Administering prescribed antibiotics:Antibiotics are biologically inert against viruses as they target bacterial structures like cell walls or 70S ribosomes. Administering them for a viral etiology is inappropriate and contributes to the proliferation of multidrug-resistant organisms. They should only be used if a bacterial co-infection is definitively diagnosed.
Correct Answer is D
Explanation
A. Ignore the error if there are no visible critical outcomes:This action is unethical and violates the nursing code of conduct regarding accountability and patient safety. Even "near misses" or errors without harm provide valuable data for systemic improvements in EBP. Concealing errors prevents the implementation of safety protocols designed to protect future patients.
B. Apologize to the patient and promise it won't happen again:While an apology is part of transparent care, it is not a complete clinical response to a medication error. The nurse must follow formal reporting channels to ensure the patient is medically evaluated for adverse effects. Personal promises do not fulfill the legal or institutional requirements for error management.
C. Document the error in the patient's chart but do not communicate it:Charting is necessary, but failing to communicate the error to the healthcare team prevents immediate corrective action. SBAR communication is specifically designed to facilitate the rapid exchange of critical safety information. Silent documentation does not ensure the patient's physiological safety.
D. Report the medication error following the institution's protocol and SBAR format:Utilizing Situation, Background, Assessment, and Recommendation (SBAR) provides a structured, evidence-based method for clear communication. Prompt reporting allows for immediate clinical intervention and contributes to the facility's safety database for quality improvement. This is the highest standard of professional practice.
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