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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 B

Explanation

Nitrofurantoin is an antibiotic commonly used to treat urinary tract infections. One of the adverse eﬀects of nitrofurantoin is diarrhea, which may be severe and watery. Therefore, it is important for the home care nurse to inform the client that the diarrhea may be a side eﬀect of the medication and requires further evaluation. The nurse should instruct the client to stop taking the medication and contact their healthcare provider for further assessment and treatment. The nurse should also assess the client's ﬂuid and electrolyte status and monitor for signs of dehydration.

Option a is important to consider, but it does not address the potential adverse eﬀect of the medication.

Option c may be appropriate in some cases, but it is not the priority intervention at this time.

Option d is not necessarily true and may cause unnecessary alarm to the client.

A. Hearing has decreased. B. Decreased blood urea nitrogen. C. White blood cells count 6,000/mm3 (6x109/L). D. Reports of photophobia.

Correct Answer is A

Explanation

Gentamicin sulfate is an aminoglycoside antibiotic that can cause ototoxicity, which is damage to the inner ear leading to hearing loss or balance problems. Therefore, a decrease in hearing is an indication that the client may be experiencing an adverse eﬀect of gentamicin.

Option b, decreased blood urea nitrogen, is not an adverse eﬀect of gentamicin, but it may indicate improvement in kidney function, which can be a positive outcome of treatment.

Option c, a white blood cell count of 6,000/mm3 (6x109/L), is within the normal range and is not necessarily an adverse eﬀect of gentamicin.

Option d, photophobia, is not a common adverse eﬀect of gentamicin and may indicate a diﬀerent condition or medication eﬀect.

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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

Two months after taking nitrofurantoin for a bacterial infection, a client reports the onset of severe, watery diarrhea to the home care nurse. How should the nurse respond?

Correct Answer is B

Explanation

A male client has been receiving the antibiotic gentamicin sulfate IV piggyback every 12 hours for several days. Which observations by the nurse indicate that the client may be experiencing an adverse eﬀect of gentamicin?

Correct Answer is A

Explanation

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