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.
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Correct Answer is A
Explanation
Choice A reason:
Rinsing the mouth with water after using an inhaler, especially one containing corticosteroids, is crucial to prevent oral thrush (a fungal infection) and reduce irritation in the mouth and throat. This practice helps maintain oral hygiene and ensures the medication does not linger in the mouth, which can cause side effects.
Choice B reason:
Using the inhaler during meals to mask the taste of the medication is not recommended. Inhalers should be used as prescribed, and the technique should not be altered to mask the taste. Proper inhaler technique is essential for the medication to reach the lungs effectively.
Choice C reason:
Limiting caffeinated beverages to two cups per day is generally good advice for overall health, but it is not directly related to the use of an inhaler. Caffeine can sometimes exacerbate symptoms of asthma or other respiratory conditions, but this is not a primary instruction for inhaler use.
Choice D reason:
Using the inhaler before bed at night may be part of a prescribed regimen, but it is not a general instruction that indicates understanding of inhaler use. The timing of inhaler use should follow the healthcare provider’s instructions, which may vary depending on the medication and the individual’s condition.
Correct Answer is C
Explanation
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.