The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?
Count the apical and radial pulses simultaneously.
Observe for edema around the ankles.
Auscultate the client’s bowel sounds.
Measure the client’s capillary glucose level.
The Correct Answer is C
Choice A reason:
Counting the apical and radial pulses simultaneously can help detect pulse deficits, which may indicate cardiac issues. However, this is not the most critical assessment for a client receiving hydromorphone.
Choice B reason:
Observing for edema around the ankles is important for assessing fluid retention and potential heart failure. While relevant, it is not the primary concern for a client on hydromorphone.
Choice C reason:
Auscultating the client’s bowel sounds is crucial because hydromorphone, like other opioids, can cause constipation and potentially lead to paralytic ileus, a serious condition where the intestines stop moving food through. Monitoring bowel sounds helps detect early signs of this complication.
Choice D reason:
Measuring the client’s capillary glucose level is important for diabetic patients or those at risk of hyperglycemia. However, it is not directly related to the administration of hydromorphone.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A Reason:
Taking the medications at least 12 hours apart does not address the interaction between erythromycin and oral contraceptives. Erythromycin can reduce the effectiveness of oral contraceptives by increasing the metabolism of the hormones in the contraceptive, leading to a higher risk of unintended pregnancy. Therefore, simply spacing out the medications will not mitigate this risk.
Choice B Reason:
Stopping the oral contraceptive immediately is not advisable without consulting a healthcare provider. Abruptly discontinuing the contraceptive can lead to hormonal imbalances and unintended pregnancy. The primary concern with erythromycin is its potential to reduce the effectiveness of the contraceptive, not that it necessitates stopping the contraceptive altogether.
Choice C Reason:
Using an additional form of contraception is the most appropriate advice. Erythromycin can interfere with the effectiveness of oral contraceptives, so using a backup method, such as condoms, is recommended to prevent unintended pregnancy. This ensures that the client remains protected while taking both medications.
Choice D Reason:
Avoiding prolonged exposure to direct sunlight is not relevant to the interaction between erythromycin and oral contraceptives. While some medications can increase photosensitivity, this is not a primary concern with erythromycin in the context of contraceptive use.
Correct Answer is C
Explanation
Choice A Reason:
Initiating cardiopulmonary resuscitation (CPR) is a critical action when a patient is in cardiac arrest or not breathing. However, in this scenario, the client is experiencing severe respiratory depression due to opioid overdose, and the first line of treatment is to administer naloxone. If the client does not respond to naloxone, then CPR may be necessary, but the immediate step is to address the opioid toxicity.
Choice B Reason:
Preparing to assist with chest tube insertion is not relevant in this context. Chest tubes are typically used to treat conditions like pneumothorax or pleural effusion. The client’s symptoms are due to opioid-induced respiratory depression, which requires naloxone administration rather than chest tube insertion.
Choice C Reason:
Administering a second dose of naloxone is the appropriate action. Naloxone is an opioid antagonist that reverses the effects of opioid overdose, including respiratory depression. Given the client’s critically low respiratory rate and oxygen saturation, a second dose of naloxone is necessary to counteract the opioid effects and restore normal breathing.
Choice D Reason:
Determining the Glasgow Coma Scale (GCS) score is useful for assessing the level of consciousness, but it does not directly address the immediate need to reverse the opioid-induced respiratory depression. The priority is to administer naloxone to improve the client’s respiratory status. Once the client is stabilized, further assessments, including the GCS score, can be conducted.