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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

Explanation

Lithium carbonate is a mood stabilizer commonly used to treat bipolar disorder. However, it has a narrow therapeutic index and requires careful monitoring of serum levels to avoid toxicity. One of the major concerns with lithium therapy is the potential for drug interactions and toxicity. NSAIDs such as ibuprofen and naproxen can increase lithium levels by reducing its excretion and can lead to lithium toxicity. Therefore, it is essential to instruct the client to eliminate the use of NSAIDs while taking lithium.

Option b) Avoid consuming all foods that contain iodine is incorrect because iodine is not contraindicated with lithium. However, excessive iodine intake can interfere with thyroid function, which can exacerbate mood instability.

Option c) Notify healthcare provider prior to dental procedures is not specific to lithium therapy and is a general precaution that patients with bipolar disorder should follow before any medical or dental procedures.

Option d) Monitor blood glucose levels daily is also not directly related to lithium therapy. While lithium can cause diabetes insipidus, which can lead to excessive thirst and urination, it does not typically aﬀect blood glucose levels.

A. Unusual irritability. B. Diarrhea C. Nausea D. Involuntary movements.

Correct Answer is D

Explanation

Metoclopramide is a medication used to treat nausea and vomiting, including those caused by chemotherapy. However, it has a potential adverse eﬀect of causing extrapyramidal symptoms (EPS), which are involuntary movements of the body, such as muscle spasms, twitching, or restlessness. These symptoms can be distressing for patients and can interfere with their quality of life. EPS can be a sign of tardive dyskinesia, a serious and irreversible neurological disorder.

Therefore, it is essential for the nurse to monitor the client for any signs of EPS and report them immediately to the healthcare provider to prevent further complications. Unusual irritability, diarrhea, and nausea are also potential adverse eﬀects of metoclopramide, but they are not as concerning as EPS.

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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

A client with bipolar disorder admitted with severe depression and suicidal ideation receives a prescription for lithium carbonate, which instruction should the nurse provide to the client?

Correct Answer is A

Explanation

A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse eﬀect is most important for the nurse to report?

Correct Answer is D

Explanation

Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?

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

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