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

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

Advise 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.

Answer and Explanation

The Correct Answer is D

Choice A reason: Telling the client to notify the nurse if the pain is not relieved is an important nursing action, but it is not the highest priority. The nurse should assess the client's pain level before and after administering the medication, and evaluate its effectiveness. If the pain is not relieved, the nurse should report it to the prescriber and consider other interventions.

Choice B reason: Advising the client that the medication should start to work in about 30 minutes is an informative nursing action, but it is not the highest priority. The nurse should educate the client about the expected onset, peak, and duration of action of the medication, and how to take it safely and effectively. However, this does not address any immediate risks or needs of the client.

Choice C reason: Administering a stool softener/laxative at the same time as the analgesic is a preventive nursing action, but it is not the highest priority. The nurse should anticipate and prevent potential side effects of the medication, such as constipation, which can be caused by codeine. However, this does not address any urgent or emergent issues of the client.

Choice D reason: Instructing the client to request assistance when ambulating to the bathroom is the highest priority nursing action, as it addresses a serious safety concern of the client. The nurse should protect the client from falls and injuries, which can be caused by codeine's sedative and drowsy effects. The nurse should also monitor the client's respiratory rate and level of consciousness, as codeine can cause respiratory depression and altered mental status.

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Correct Answer is A

Explanation

Choice A reason: Zolpidem is a hypnotic drug that induces sleep by enhancing the activity of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity. Zolpidem is used to treat insomnia, or difficulty falling asleep or staying asleep. Zolpidem should be taken only at bedtime, when the client is ready to go to sleep and can devote at least seven to eight hours for uninterrupted sleep. Taking zolpidem during the day can cause excessive sedation, drowsiness, confusion, memory loss, and impaired coordination. Therefore, the nurse should encourage the client to wait until bedtime to take the medication and avoid daytime naps.

Choice B reason: Reminding the client to drink plenty of fluids when taking the medication is not an action that the nurse should take in this situation, but rather a general recommendation that applies to most medications. Drinking fluids can help to prevent dehydration, flush out toxins, and maintain kidney function. However, drinking fluids is not specific to zolpidem and does not affect its absorption or metabolism.

Choice C reason: Advising the client to take the medication with the noon meal is not an action that the nurse should take in this situation, but rather a harmful suggestion that can reduce the effectiveness of zolpidem and increase its side effects. Taking zolpidem with food can delay its onset of action and make it less potent. Taking zolpidem at noon can also interfere with the client's circadian rhythm, or natural sleep-wake cycle, and cause daytime sleepiness and nighttime insomnia.

Choice D reason: Explaining that the client needs to allow for sleep time of at least two hours is not an action that the nurse should take in this situation, but rather an inaccurate and insufficient information that can mislead the client and endanger their safety. Zolpidem has a half-life of about two hours, which means that half of its dose is eliminated from the body in two hours. However, this does not mean that its effects wear off in two hours. Zolpidem can still cause residual sedation and impairment for several hours after taking it. The client needs to allow for sleep time of at least seven to eight hours when taking zolpidem, not just two hours.

A. Hold the calcitriol but administer the calcium carbonate as scheduled. B. Hold the calcium carbonate, but administer the calcitriol as scheduled. C. Hold both medications until contacting the healthcare provider. D. Administer both prescribed medications as scheduled.

Correct Answer is C

Explanation

Choice A reason: Holding the calcitriol but administering the calcium carbonate as scheduled is not appropriate, as both drugs can increase the serum calcium level and worsen the condition of hypercalcemia. Calcitriol is a synthetic form of vitamin D that enhances the absorption of calcium from the GI tract and promotes bone mineralization. Calcium carbonate is a supplement that provides additional calcium to the body.

Choice B reason: Holding the calcium carbonate, but administering the calcitriol as scheduled is not appropriate, as calcitriol alone can also raise the serum calcium level and cause hypercalcemia. Calcitriol is a synthetic form of vitamin D that enhances the absorption of calcium from the GI tract and promotes bone mineralization.

Choice C reason: Holding both medications until contacting the healthcare provider is the appropriate action to take, as the client's total calcium level is above the normal range of 9 to 10.5 mg/dL or 2.25 to 2.62 mmol/L and indicates hypercalcemia. Hypercalcemia can cause symptoms such as nausea, vomiting, constipation, confusion, lethargy, muscle weakness, cardiac arrhythmias, and kidney stones. The healthcare provider can adjust the dose or frequency of the medications or prescribe other treatments to lower the serum calcium level.

Choice D reason: Administering both prescribed medications as scheduled is not appropriate, as both drugs can increase the serum calcium level and worsen the condition of hypercalcemia. Calcitriol is a synthetic form of vitamin D that enhances the absorption of calcium from the GI tract and promotes bone mineralization. Calcium carbonate is a supplement that provides additional calcium to the body.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Prior to administering oral doses of calcitriol and calcium carbonate to a client with hypoparathyroidism, the nurse notes that the client's total calcium level is 14 mg/dL (3.5 mmol/L). Which action should the nurse implement?

Correct Answer is C

Explanation

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