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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Diabetes insipidus is a condition in which the kidneys are unable to conserve water, leading to excessive thirst and urination. It is treated with antidiuretic hormone (ADH), which helps the kidneys retain water and reduce urine output. When caring for a client with diabetes insipidus who is receiving ADH intranasally, it is important for the nurse to monitor the client’s serum osmolality.
Osmolality is a measure of the concentration of particles in a solution and can provide information about the client’s hydration status.
Monitoring serum osmolality can help determine if the ADH therapy is effective in managing the client’s diabetes insipidus.
Correct Answer is C
Explanation
Ipratropium is a medication used to treat chronic obstructive pulmonary disease (COPD)1. When using an ipratropium inhaler for the first time or if it has not been used for a while, it is important to prime the inhaler by spraying it into the air away from your face1. However, the inhaler only needs to be primed with 2 sprays, not 71. If the client primes the inhaler with 7 pumps, it indicates that additional teaching is needed.
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