Which nursing action has the highest priority when administering a dose of codeine with acetaminophen to a client?
Explanation & Rationale
Choice A rationaleCodeine is an opioid medication that can cause drowsiness and dizziness. This can increase the risk of falls, particularly in older adults or those with balance or mobility issues. Therefore, it is important to instruct the client to request assistance when ambulating to prevent falls.Choice B rationaleWhile constipation is a common side effect of opioid medications like codeine, and a stool softener or laxative may be helpful in managing this side effect, it is not the highest priority nursing action. The risk of falls due to drowsiness or dizziness is a more immediate safety concern.Choice C rationaleWhile it is important for the client to notify the nurse if the pain is not relieved, this is not the highest priority nursing action. The safety of the client is the primary concern, and preventing falls by providing assistance with ambulation is a more immediate need.Choice D rationaleAdvising the client that the medication should start to work in about 30 minutes is an important part of patient education, but it is not the highest priority nursing action. The safety of the client is the primary concern, and preventing falls by providing assistance with ambulation is a more immediate need.