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","B","C","E"]
Explanation
Choice A reason:
Lisinopril is an ACE inhibitor that is commonly prescribed for once-daily dosing. It is effective in managing hypertension and heart failure with a single daily dose, making it convenient for patients who may have difficulty remembering multiple doses12.
Choice B reason:
Quinapril can also be administered once daily. It is used to treat hypertension and heart failure, and its long half-life allows for effective blood pressure control with a single daily dose.
Choice C reason:
Ramipril is another ACE inhibitor that can be given once daily. It is used for hypertension, heart failure, and to reduce the risk of cardiovascular events. Its pharmacokinetics support once-daily dosing, which helps improve patient adherence.
Choice D reason:
Captopril is typically not given once daily due to its shorter half-life. It usually requires multiple doses throughout the day to maintain effective blood pressure control.
Choice E reason:
Trandolapril is an ACE inhibitor that can be administered once daily. It is used for hypertension and heart failure, and its long duration of action supports once-daily dosing.
Correct Answer is D
Explanation
Choice A Reason:
Polyuria, or excessive urination, is a symptom of diabetes insipidus rather than a side effect of vasopressin. Vasopressin is used to reduce urine output in DI patients. If polyuria persists, it may indicate that the medication is not effective, but it is not a direct side effect that requires immediate reporting.
Choice B Reason:
Low urine specific gravity indicates dilute urine, which is a characteristic of diabetes insipidus. Vasopressin should help concentrate the urine. If low urine specific gravity persists, it may suggest that the medication is not working effectively, but it is not a side effect that necessitates urgent reporting.
Choice C Reason:
Polydipsia, or excessive thirst, is another symptom of diabetes insipidus. While vasopressin should help reduce this symptom by controlling urine output, persistent polydipsia may indicate inadequate treatment. However, it is not a side effect of the medication that requires immediate attention.
Choice D Reason:
Worsening headache is a significant side effect that should be reported to the healthcare provider. Headaches can indicate water intoxication or hyponatremia (low sodium levels), which are serious complications of vasopressin therapy. Immediate reporting is necessary to adjust the treatment and prevent further complications.