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Which nursing action has the highest priority when administering a dose of codeine with acetaminophen to a client?
- A. Instruct the client to request assistance when ambulating to the bathroom.
- B. Administer a stool softener/laxative at the same time as the analgesic.
- C. Tell the client to notify the nurse if the pain is not relieved.
- D. Advise the client that the medication should start to work in about 30 minutes.
Correct Answer: A
Rationale: Codeine, an opioid, causes drowsiness and dizziness, increasing fall risk. Instructing the client to request assistance when ambulating (A) is the highest priority for safety. Stool softeners (B) address constipation but are secondary. Notifying about unrelieved pain (C) and onset time (D) are important but not immediate safety concerns.
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The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?
- A. Administer a second dose of naloxone.
- B. Prepare to assist with chest tube insertion.
- C. Determine Glasgow Coma Scale score.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: D
Rationale: Severe respiratory depression (4 breaths/min), hypoxia (75% SpO₂), and unresponsiveness require immediate CPR (D) to restore circulation/oxygenation. A second naloxone dose (A) may be needed but is secondary. Chest tubes (B) are irrelevant. Glasgow scoring (C) delays critical intervention.
A patient with heart failure develops hyperaldosteronism and is prescribed spironolactone. What instructions should the nurse include in the patient’s care plan?
- A. Substitute salt with a salt substitute.
- B. Protect your skin before going outside.
- C. Limit intake of high-potassium foods.
- D. Monitor skin for excessive bruising.
Correct Answer: C
Rationale: This question is identical to Question 7. Spironolactone increases potassium retention, so limiting high-potassium foods (C) prevents hyperkalemia. Salt substitutes (A) contain potassium. Sun protection (B) and bruising (D) are unrelated. Note: Duplicate question; consider removing.
While evaluating a patient who has been taking acetaminophen for chronic pain, the nurse notices that the patient’s skin appears yellow. What action should the nurse take in response to this observation?
- A. Suggest the patient to reduce the dosage of the medication.
- B. Check the patient’s capillary glucose level.
- C. Use a pulse oximeter to assess the patient’s oxygen saturation.
- D. Report the observation to the healthcare provider.
Correct Answer: D
Rationale: Yellow skin (jaundice) suggests liver damage, a serious acetaminophen side effect. Reporting to the provider (D) is critical for evaluation. Reducing dosage (A) without consultation is unsafe. Glucose (B) and oxygen saturation (C) are unrelated to jaundice.
A patient who is taking albendazole reports experiencing fatigue, nausea, and dark urine. The nurse observes a yellowing of the patient’s skin and sclera. Which laboratory result should the nurse review?
- A. Thyroid function test.
- B. Liver function test.
- C. Renal function panel.
- D. Basic metabolic panel.
Correct Answer: B
Rationale: Albendazole can cause hepatotoxicity, indicated by fatigue, nausea, dark urine, and jaundice. Reviewing liver function tests (B) assesses damage. Thyroid (A), renal (C), and metabolic panels (D) are unrelated to these symptoms.
A patient who received a renal transplant three months ago is readmitted to the acute care unit with signs of graft rejection. During the patient’s history taking, the nurse finds out that the patient has been self-administering St. John’s Wort, an herbal preparation, on a friend’s advice. What information is most significant about this finding?
- A. St. John’s Wort can decrease plasma concentrations of cyclosporine.
- B. Consumption of St. John’s Wort can reduce the patient’s sodium intake.
- C. Adding the herb can decrease the need for corticosteroids.
- D. The patient probably used this herb to treat depression.
Correct Answer: A
Rationale: St. John’s Wort induces CYP3A4, reducing cyclosporine levels (A), risking transplant rejection. It doesn’t affect sodium (B) or reduce corticosteroid needs (C). Depression treatment (D) is secondary to the transplant risk.