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:
Glucagon is a hormone used to treat severe hypoglycemia (low blood sugar) in individuals with diabetes. Severe hypoglycemia can be life-threatening and requires immediate treatment to raise blood sugar levels. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. It is crucial for clients and their families to recognize the signs of severe hypoglycemia, such as confusion, unconsciousness, or seizures, and to administer glucagon promptly.
Choice B Reason:
Administering glucagon before meals to prevent hyperglycemia is incorrect. Glucagon is not used to prevent high blood sugar levels; it is specifically used to treat low blood sugar levels. Preventing hyperglycemia typically involves insulin administration and dietary management, not glucagon.
Choice C Reason:
While managing blood sugar levels during sick days is important, glucagon is not used for this purpose. Clients are usually advised to monitor their blood sugar levels more frequently and adjust their insulin doses as needed during illness. Glucagon is reserved for emergency situations involving severe hypoglycemia.
Choice D Reason:
Glucagon is not used to treat diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes that requires immediate medical attention and is treated with insulin, fluids, and electrolytes. Administering glucagon would not address the underlying issues of DKA and could potentially worsen the condition.
Correct Answer is A
Explanation
Choice A reason:
Measuring the client’s blood pressure is the most direct and effective way to assess the effectiveness of amlodipine. Amlodipine is a calcium channel blocker primarily used to treat hypertension and angina. Its main action is to relax the blood vessels, which lowers blood pressure. Regular monitoring of blood pressure helps determine if the medication is achieving its intended effect.
Choice B reason:
Monitoring the client’s serum electrolytes is important for overall health, but it is not the primary method to assess the effectiveness of amlodipine. Amlodipine does not significantly affect serum electrolyte levels, so this action would not provide specific information about the drug’s effectiveness.
Choice C reason:
Noting the client’s serum calcium levels is not necessary for assessing the effectiveness of amlodipine. Amlodipine does not alter serum calcium levels, as its mechanism of action involves blocking calcium channels in the blood vessels, not affecting calcium levels in the blood.
Choice D reason:
Reviewing the client’s intake and output can be useful for monitoring fluid balance and kidney function, but it is not the primary method to assess the effectiveness of amlodipine. This action does not directly measure the drug’s impact on blood pressure.