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 D
Explanation
Guaifenesin is an expectorant that helps to loosen and thin mucus in the airways, making it easier to cough up. It is commonly used to manage symptoms of a chronic productive cough in conditions such as COPD.
Salmeterol and Tiotropium are both bronchodilators that help to open up the airways and improve breathing in COPD, but they are not specifically indicated for managing a chronic productive cough.
Prednisone is a corticosteroid that can help reduce inflammation in the airways and improve breathing in COPD exacerbations, but it is not typically used for managing a chronic productive cough.
Correct Answer is B
Explanation
Metformin is a medication that can affect kidney function. Since contrast dye used in CT scans is processed through the kidneys, it is important for the nurse to follow up on the client’s use of metformin before the CT scan with contrast. The client may need to temporarily stop taking metformin before and after the procedure to prevent any potential harm to their kidneys.
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