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: 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.

A. Hemoglobin level of 13.5 g/dL (135 g/L). B. Serum glucose level of 120 mg/dL (6.7 mmol/L). C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L). D. Serum ammonia level of 30 mg/dL (17.62 µmol/L).

Correct Answer is C

Explanation

Choice C reason: Sodium polystyrene sulfonate is a cation-exchange resin that binds to potassium in the intestine and removes it from the body through the stool. Sodium polystyrene sulfonate is used to treat hyperkalemia, or high potassium level, which can be caused by AKI, certain medications, or other conditions. Hyperkalemia can cause cardiac arrhythmias, muscle weakness, paralysis, or death. The normal range of potassium for adults is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, a decrease in potassium from above normal to within normal indicates that sodium polystyrene sulfonate has been effective in lowering potassium level and preventing complications. The nurse should monitor the client's serum potassium level regularly and adjust the dose of sodium polystyrene sulfonate as needed.

Choice A reason: Hemoglobin level of 13.5 g/dL (135 g/L) is not a laboratory finding that indicates that the medication has been effective, but rather a normal value that reflects the amount of oxygen-carrying protein in the blood. Hemoglobin is not affected by sodium polystyrene sulfonate or potassium level. The normal range of hemoglobin for adults is 12 to 16 g/dL (120 to 160 g/L). Therefore, a hemoglobin level of 13.5 g/dL does not indicate any change or improvement in the client's condition.

Choice B reason: Serum glucose level of 120 mg/dL (6.7 mmol/L) is not a laboratory finding that indicates that the medication has been effective, but rather a slightly elevated value that reflects the amount of sugar in the blood. Glucose is not affected by sodium polystyrene sulfonate or potassium level. The normal range of glucose for adults is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Therefore, a serum glucose level of 120 mg/dL may indicate impaired glucose metabolism or diabetes mellitus, but not the effectiveness of sodium polystyrene sulfonate.

Choice D reason: Serum ammonia level of 30 mg/dL (17.62 µmol/L) is not a laboratory finding that indicates that the medication has been effective, but rather a normal value that reflects the amount of nitrogen waste in the blood. Ammonia is not affected by sodium polystyrene sulfonate or potassium level. The normal range of ammonia for adults is 10 to 80 mg/dL (6 to 47 µmol/L). Therefore, a serum ammonia level of 30 mg/dL does not indicate any change or improvement in the client's condition.

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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

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

Correct Answer is C

Explanation

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