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 C

Explanation

Choice A reason: Nausea and diarrhea are possible side effects of ginkgo biloba, but they are not as serious or common as the risk of bleeding caused by the interaction with aspirin and non-steroidal anti-inflammatory drugs. Therefore, this information is not as important as choice c.

Choice B reason: Anxiety and headaches are not associated with the use of ginkgo biloba, but rather with the underlying condition of multiple sclerosis. Therefore, this information is not relevant or accurate for this client.

Choice C reason: Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo biloba, as both substances have antiplatelet effects that can increase the risk of bleeding. Therefore, this information is most important for the nurse to include in the teaching plan for this client, as the client should avoid taking these drugs while using ginkgo biloba or inform the healthcare provider if they are prescribed.

Choice D reason: Ginkgo biloba use should be limited and not taken during pregnancy, as there is insufficient evidence about its safety and efficacy for pregnant women. However, this information is not as important as choice c, as the client may not be pregnant or planning to become pregnant.

A. Check the client's capillary glucose level. B. Advise the client to reduce the medication dose. C. Report the finding to the healthcare provider. D. Use a pulse oximeter to assess oxygen saturation.

Correct Answer is C

Explanation

Choice A reason: Checking the client's capillary glucose level is not relevant to this finding, as acetaminophen does not affect blood glucose levels. The yellow color of the skin may indicate jaundice, which is a sign of liver damage caused by acetaminophen overdose or toxicity.

Choice B reason: Advising the client to reduce the medication dose is not sufficient to address this finding, as acetaminophen can cause irreversible liver damage if taken in excess or for prolonged periods. The client may need immediate medical attention and treatment with an antidote such as N-acetylcysteine.

Choice C reason: Reporting the finding to the healthcare provider is the appropriate action to take, as the yellow color of the skin may indicate jaundice, which is a sign of liver failure caused by acetaminophen overdose or toxicity. The healthcare provider can order further tests and interventions to assess and treat the client's condition.

Choice D reason: Using a pulse oximeter to assess oxygen saturation is not related to this finding, as acetaminophen does not affect oxygen levels. The yellow color of the skin may indicate jaundice, which is a sign of liver dysfunction caused by acetaminophen overdose or toxicity.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba. Which information is most important for the nurse to include in the teaching plan for this client?

Correct Answer is C

Explanation

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

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