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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Replacing leafy vegetables with a protein source is not necessary or advisable for a vegetarian client who takes warfarin. Leafy vegetables are rich in vitamin K, which can interfere with warfarin's anticoagulant effect, but they also provide other nutrients and benefits for health. Protein sources such as nuts or beans may also contain vitamin K or other substances that can affect warfarin's action.
Choice B reason: Commending the client for her healthy lifestyle and encouraging her to continue her current diet habits is not appropriate or safe for a vegetarian client who takes warfarin. Leafy vegetables can alter warfarin's anticoagulant effect and increase the risk of bleeding or clotting complications if not monitored closely by the healthcare provider.
Choice C reason: Advising the client that the healthcare provider needs to be made aware of her current diet is the best response for a vegetarian client who takes warfarin. Leafy vegetables can affect warfarin's anticoagulant effect by increasing vitamin K levels in the body, which counteracts warfarin's action. The healthcare provider can adjust the warfarin dose accordingly and monitor the client's international normalized ratio (INR), which is a measure of blood clotting time.
Choice D reason: Confirming that her diet choices will help the medication be more effective in preventing blood clots is incorrect and misleading for a vegetarian client who takes warfarin. Leafy vegetables can decrease warfarin's anticoagulant effect by increasing vitamin K levels in the body, which enhances blood clotting. This can reduce the effectiveness of warfarin and increase the risk of thromboembolic events, such as stroke or pulmonary embolism.
Correct Answer is ["B","C","E"]
Explanation
Choice B reason: Ciprofloxacin is a fluoroquinolone antibiotic that can treat anthrax, a serious bacterial infection that can affect the skin, lungs, or digestive system. Ciprofloxacin can cause tendonitis or tendon rupture, especially in older adults or those who take corticosteroids. Tendonitis is the inflammation of a tendon, which is a tissue that connects muscle to bone. Tendon rupture is the tearing or breaking of a tendon. These conditions can cause severe pain, swelling, bruising, or difficulty moving the affected area. Therefore, the nurse should instruct the client to report any tendon pain or swelling to the healthcare provider immediately and stop taking ciprofloxacin until further evaluation.
Choice C reason: Increasing fluid intake while taking the medication is an instruction that should be included in the teaching plan, because ciprofloxacin can cause crystalluria, or the formation of crystals in the urine. Crystalluria can lead to kidney stones, kidney damage, or urinary tract obstruction. Therefore, the nurse should advise the client to drink at least 2 liters of water per day while taking ciprofloxacin to prevent crystalluria and maintain kidney function.
Choice E reason: Limiting exposure to sunlight and avoiding tanning beds is an instruction that should be included in the teaching plan, because ciprofloxacin can cause photosensitivity, or increased sensitivity to sunlight or artificial ultraviolet light. Photosensitivity can result in sunburn, rash, blisters, or skin discoloration. Therefore, the nurse should recommend the client to limit exposure to sunlight and avoid tanning beds while taking ciprofloxacin and for several days after finishing the course. The nurse should also suggest the client to wear protective clothing, sunglasses, and sunscreen when outdoors.
Choice A reason: Crushing and mixing the tablets with pudding if you have trouble swallowing the tablets is not an instruction that should be included in the teaching plan, but rather a contraindicated practice that can reduce the effectiveness of ciprofloxacin and increase its side effects. Ciprofloxacin tablets have a special coating that protects them from stomach acid and allows them to dissolve slowly in the intestine. Crushing them will destroy their coating and make them dissolve faster in the stomach. This can cause stomach irritation, nausea, vomiting, diarrhea, or reduced absorption of ciprofloxacin into the bloodstream. Therefore, the nurse should instruct the client to swallow the tablets whole and not chew or crush them.
Choice D reason: Using NSAIDs to relieve mild joint aches and pains caused by the medication is not an instruction that should be included in the teaching plan, but rather a risky behavior that can increase the risk of adverse effects from ciprofloxacin. NSAIDs are anti-inflammatory drugs that can reduce pain, fever, and inflammation. However, NSAIDs can also interact with ciprofloxacin and increase its concentration in the blood. This can lead to toxicity and serious side effects such as seizures, hallucinations, confusion, or liver damage. Therefore, the nurse should caution the client to avoid using NSAIDs while taking ciprofloxacin and consult with their healthcare provider before taking any other medications.
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