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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Taking levothyroxine on an empty stomach ensures better absorption and prevents interference from food or other medications. The client should take levothyroxine at least 30 minutes before breakfast or four hours after the last meal of the day.

Choice B reason: Consuming foods that are high in iodine is not recommended for clients taking levothyroxine, as it may affect the thyroid function and the dosage of the medication. Foods that are high in iodine include seafood, seaweed, dairy products, and iodized salt.

Choice C reason: Administering levothyroxine at bedtime is not advisable, as it may cause insomnia, anxiety, or palpitations. Levothyroxine is best taken in the morning, as it mimics the natural secretion of thyroid hormones.

Choice D reason: Avoiding the use of iron supplements is not necessary for clients taking levothyroxine, as long as they are taken at different times. Iron supplements can interfere with the absorption of levothyroxine, so they should be taken at least four hours apart.

A. Notify the healthcare provider of the carbamazepine level. B. Administer the carbamazepine as prescribed. C. Assess the client for side effects of carbamazepine. D. Withhold this dose of the carbamazepine.

Correct Answer is A

Explanation

Choice A reason: Notifying the healthcare provider of the carbamazepine level is the most appropriate action for the nurse to take. Carbamazepine is an anticonvulsant drug that requires close monitoring of its serum levels to ensure therapeutic and safe effects. The normal reference range for carbamazepine is 4 to 12 mcg/mL or 16.9 to 50.8 mmol/L. A level of 84 mcg/L (35.6 mmol/L) is significantly higher than the upper limit and indicates toxicity. The nurse should report this finding to the prescriber immediately and hold the dose until further instructions.

Choice B reason: Administering the carbamazepine as prescribed is not the most appropriate action for the nurse to take. Giving the evening dose of carbamazepine when the morning level is already toxic can worsen the client's condition and cause serious adverse effects, such as confusion, drowsiness, ataxia, nystagmus, or coma. The nurse should not administer the medication without consulting the prescriber.

Choice C reason: Assessing the client for side effects of carbamazepine is an important action for the nurse to take, but it is not the most appropriate one. The nurse should assess the client for signs and symptoms of carbamazepine toxicity, such as nausea, vomiting, headache, blurred vision, or seizures. However, this action alone is not sufficient to address the problem. The nurse should also notify the prescriber and withhold the dose.

Choice D reason: Withholding this dose of the carbamazepine is a necessary action for the nurse to take, but it is not the most appropriate one. The nurse should not give the evening dose of carbamazepine when the morning level is already toxic, as this can increase the risk of complications. However, this action alone is not enough to resolve the issue. The nurse should also notify the prescriber and follow the appropriate interventions.

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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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Naxlex Comprehensive Predictor Exams

A client receives a new prescription for levothyroxine. Which statement made by the client indicates to the nurse that the education was effective?

Correct Answer is A

Explanation

Prior to administering the evening dose of carbamazepine, the nurse notes that the client's morning carbamazepine level was 84 mcg/L (35.6 mmol/L). Which action should the nurse take?

Correct Answer is A

Explanation

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