Which nursing action has the highest priority when administering a dose of codeine with acetaminophen to a client?
Instruct the client to request assistance when ambulating to the bathroom.
Administer a stool softener/laxative at the same time as the analgesic.
Advise the client that the medication should start to work in about 30 minutes.
Tell the client to notify the nurse if the pain is not relieved.
The Correct Answer is A
Choice A reason: This is the highest priority action for the nurse to take. Codeine is an opioid analgesic that can cause drowsiness, dizziness, and impaired coordination. These effects can increase the risk of falls and injuries in the client, especially when ambulating to the bathroom. The nurse should instruct the client to request assistance when getting out of bed or walking, and provide adequate support and supervision.
Choice B reason: This is not the highest priority action for the nurse to take. Administering a stool softener/laxative at the same time as the analgesic is a preventive measure that can help reduce the risk of constipation, which is a common side effect of codeine. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.
Choice C reason: This is not the highest priority action for the nurse to take. Advising the client that the medication should start to work in about 30 minutes is an informative and reassuring measure that can help the client cope with pain and anxiety. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.
Choice D reason: This is not the highest priority action for the nurse to take. Telling the client to notify the nurse if the pain is not relieved is an evaluative and responsive measure that can help the nurse monitor the effectiveness of the analgesic and adjust the dosage or frequency as needed. However, this action is not as urgent or important as ensuring the client's safety and preventing falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A basic metabolic panel is a blood test that measures the levels of electrolytes, glucose, blood urea nitrogen, creatinine, and calcium in the body. It can be used to assess the fluid balance, kidney function, and acid-base balance of the client. However, it does not provide information about the liver function, which is the most likely cause of the client's symptoms.
Choice B reason: A thyroid function test is a blood test that measures the levels of thyroid hormones and thyroid-stimulating hormone in the body. It can be used to diagnose thyroid disorders, such as hypothyroidism or hyperthyroidism, which can affect the metabolism, energy, and mood of the client. However, it does not provide information about the liver function, which is the most likely cause of the client's symptoms.
Choice C reason: A renal function panel is a blood test that measures the levels of creatinine, blood urea nitrogen, and uric acid in the body. It can be used to assess the kidney function and the excretion of waste products from the body. However, it does not provide information about the liver function, which is the most likely cause of the client's symptoms.
Choice D reason: A liver function test is a blood test that measures the levels of enzymes, proteins, and bilirubin in the body. It can be used to assess the liver function and the production and metabolism of bile. Albendazole is a medication that can cause liver toxicity and hepatitis, which can lead to symptoms such as fatigue, nausea, dark urine, and jaundice. The nurse should review the liver function test to monitor the client's liver status and adjust the medication dose accordingly.
Correct Answer is D
Explanation
Choice A reason: This is not an appropriate action for the nurse to take. Increasing the intake of saturated fats will worsen the side effects of orlistat, which inhibits the absorption of fats in the intestine. The client should be advised to follow a low-fat diet while taking orlistat.
Choice B reason: This is not an appropriate action for the nurse to take. Oily stools and flatus are common and expected side effects of orlistat, and they do not indicate a serious adverse reaction. The client does not need to stop taking the drug or contact her healthcare provider unless the symptoms are severe or persistent.
Choice C reason: This is not an appropriate action for the nurse to take. Obtaining a stool specimen to evaluate for occult blood and fat content is not necessary for a client taking orlistat. The presence of fat in the stool is normal and expected with orlistat, and there is no evidence of bleeding in the client's case.
Choice D reason: This is the appropriate action for the nurse to take. Asking the client to describe her dietary intake history for the last several days will help the nurse assess the client's compliance with the recommended low-fat diet and provide education and counseling as needed. The nurse can also monitor the client's weight loss progress and adjust the dosage of orlistat accordingly.
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