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

Advice 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.

Tell the client to notify the nurse if the pain is not relieved.

Answer and Explanation

The Correct Answer is C

The correct answer is C. Instruct the client to request assistance when ambulating to the bathroom.

Choice A reason:

Advise the client that the medication should start to work in about 30 minutes.

While it is important to inform the client about the onset of action of the medication, this is not the highest priority. Codeine, an opioid, can cause dizziness and sedation, which increases the risk of falls. Therefore, safety measures take precedence over informing the client about the medication’s onset time.

Choice B reason:

Administer a stool softener/laxative at the same time as the analgesic.

Opioids like codeine can cause constipation, so administering a stool softener or laxative is a good practice. However, this action is not the highest priority when considering the immediate safety of the client. Ensuring the client’s safety from potential falls due to dizziness or sedation is more urgent.

Choice C reason:

Instruct the client to request assistance when ambulating to the bathroom.

This is the correct answer because codeine can cause dizziness, sedation, and orthostatic hypotension, increasing the risk of falls. Ensuring the client requests assistance when moving can prevent potential injuries, making it the highest priority nursing action.

Choice D reason:

Tell the client to notify the nurse if the pain is not relieved.

While it is important for the client to communicate about the effectiveness of pain relief, this is not the highest priority. The immediate concern is the client’s safety due to the sedative effects of codeine. Therefore, preventing falls and injuries takes precedence.

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Correct Answer is ["A","D"]

Explanation

The correct answer is:

a. Report any tendon pain or swelling to the healthcare provider immediately.

d. Limit exposure to sunlight and avoid tanning beds.

Choice A: Report any tendon pain or swelling to the healthcare provider immediately.

Ciprofloxacin, like other fluoroquinolones, can cause tendinitis and tendon rupture. This risk is higher in older adults, those on corticosteroid therapy, and those with kidney, heart, or lung transplants. Reporting any tendon pain or swelling immediately is crucial to prevent severe complications.

Choice B: Use NSAIDS to relieve mid joint aches and pains caused by the medication.

This is not recommended. Using NSAIDs with ciprofloxacin can increase the risk of central nervous system effects, including seizures. Therefore, it is not advised to use NSAIDs to relieve joint aches and pains caused by ciprofloxacin.

Choice C: Crush and mix the tablets with pudding if you have trouble swallowing the tablets.

Ciprofloxacin tablets should not be crushed. Crushing the tablets can affect the drug’s effectiveness and increase the risk of side effects. If swallowing is an issue, the healthcare provider should be consulted for alternative forms of the medication.

Choice D: Limit exposure to sunlight and avoid tanning beds.

Ciprofloxacin can increase the skin’s sensitivity to sunlight, leading to severe sunburns. Patients are advised to limit their exposure to sunlight and avoid tanning beds while taking this medication.

A. Replace salt with a salt substitute. B. Limits intake of high-potassium foods. C. Cover your skin before going outside. D. Monitor skin for excessive bruising.

Correct Answer is B

Explanation

Spironolactone is a potassium-sparing diuretic that works by blocking the actions of aldosterone, a hormone that can lead to potassium loss in the urine. However, in some cases, spironolactone can cause hyperkalemia (high levels of potassium in the blood), which can be dangerous for patients with heart failure. Therefore, it is important to instruct the patient to limit their intake of high-potassium foods such as bananas, oranges, tomatoes, spinach, and salt substitutes containing potassium.

Option a (Replace salt with a salt substitute) is incorrect because salt substitutes often contain potassium, which can further increase the risk of hyperkalemia.

Option c (Cover your skin before going outside) is unrelated to the use of spironolactone and hyperkalemia.

Option d (Monitor skin for excessive bruising) is not directly related to the use of spironolactone and hyperkalemia, although it is a potential side eﬀect of other medications used to treat heart failure.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a discharge teaching plan for a clientwho is taking ciproﬂoxacin hydrochloride tablets which were prescribed because of a suspected anthrax exposure. Which instructions should be included in the teaching plan? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this patient’s plan of care?

Correct Answer is B

Explanation

A client is scheduled for a spiral computed topography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow-up by the nurse?

The nurse is providing instructions about a client’s new medication. How should the nurse explain the purpose of probenecid, a uricosuric drug?

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

A client taking atorvastatin becomes an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

The nurse is planning to administer the antiulcer GI agent sucralfate to a client with a peptic ulcer disease. Which action should the nurse include in this client’s plan of care?

The nurse administers risedronate to a client with osteoporosis at 07:00. The client asks for a glass of milk to drink with the medication. Which action should the nurse take?