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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View Related questions
Correct Answer is A
Explanation
Choice A Reason:
The fluticasone propionate and salmeterol discus inhalation system is designed to be used twice daily, approximately 12 hours apart. Using it more frequently can increase the risk of side effects without providing additional benefits. The medication is intended to provide long-term control of asthma symptoms, not immediate relief during an acute attack.
Choice B Reason:
There is no significant evidence to suggest that using the fluticasone propionate and salmeterol discus inhalation system causes decreased blood pressure. The primary side effects are related to the respiratory system, such as throat irritation, hoarseness, and oral thrush. Therefore, this instruction is not relevant to the proper use of the medication.
Choice C Reason:
When using the discus, the client should breathe out gently and away from the mouthpiece before inhaling the medication. Breathing out rapidly into the mouthpiece can cause the medication to be expelled from the device, reducing its effectiveness. Proper technique involves exhaling gently, then inhaling quickly and deeply through the mouthpiece.
Choice D Reason:
The fluticasone propionate and salmeterol discus inhalation system is not intended for use during an acute asthma attack. It is a maintenance medication designed to prevent asthma symptoms over time. For acute asthma attacks, a short-acting bronchodilator, such as albuterol, should be used. Using the discus during an acute attack will not provide the rapid relief needed.
Correct Answer is D
Explanation
Choice A reason:
Assessing for hypoglycemia between meals is important, but it is not the most critical intervention. Insulin lispro is a rapid-acting insulin that peaks quickly, so timing meals with insulin administration is crucial to prevent hypoglycemia.
Choice B reason:
Checking blood glucose levels every six hours is a good practice for monitoring overall glucose control, but it does not address the immediate need to coordinate insulin administration with meals to prevent hypoglycemia.
Choice C reason:
Keeping an oral liquid or glucose source available is essential for treating hypoglycemia if it occurs. However, the primary focus should be on preventing hypoglycemia by ensuring that meals are timed appropriately with insulin administration.
Choice D reason:
Providing meals at the same time insulin is given is the most important intervention. Insulin lispro acts rapidly, and if meals are not timed correctly, there is a high risk of hypoglycemia. Ensuring that the client eats at the same time as the insulin injection helps maintain stable blood glucose levels.