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 B
Explanation
Choice A reason:
Performing a bladder scan is useful for assessing urinary retention, which can be a symptom of benign prostatic hyperplasia (BPH). However, it is not the primary method for monitoring adverse reactions to tamsulosin. Tamsulosin is an alpha-1 blocker that relaxes the muscles in the prostate and bladder neck, improving urine flow. While it can help reduce urinary retention, the primary concern with tamsulosin is its effect on blood pressure.
Choice B reason:
Monitoring blood pressure is crucial because tamsulosin can cause orthostatic hypotension, a condition where blood pressure drops significantly when a person stands up from a sitting or lying position. This can lead to dizziness, lightheadedness, and even fainting. Regular monitoring of blood pressure helps detect and manage this potential adverse reaction, ensuring the client’s safety.
Choice C reason:
Obtaining daily weights is important for monitoring fluid balance and detecting conditions like heart failure or kidney disease. However, it is not directly related to the adverse reactions of tamsulosin. The primary concern with tamsulosin is its impact on blood pressure, not fluid retention.
Choice D reason:
Assessing urine output is important for evaluating the effectiveness of tamsulosin in relieving urinary symptoms associated with BPH. However, it is not the primary method for monitoring adverse reactions. The main adverse reaction to be aware of with tamsulosin is its potential to cause orthostatic hypotension, making blood pressure monitoring the priority.
Correct Answer is A
Explanation
Choice A Reason:
Sodium polystyrene sulfonate is used to treat hyperkalemia (high potassium levels) by exchanging sodium ions for potassium ions in the intestines, which are then excreted in the stool. A serum potassium level of 3.8 mEq/L is within the normal range (3.5 to 5 mEq/L), indicating that the medication has effectively reduced the potassium level to a safe range. Monitoring potassium levels is crucial in clients with AKI to prevent complications such as cardiac arrhythmias.
Choice B Reason:
A hemoglobin level of 13.3 g/dL is slightly below the normal range for adults (14 to 18 g/dL for males and 12 to 16 g/dL for females). While it is important to monitor hemoglobin levels, this value does not directly indicate the effectiveness of sodium polystyrene sulfonate, which is specifically used to manage potassium levels.
Choice C Reason:
A serum ammonia level of 30 µg/dL is within the normal range (10 to 80 µg/dL). However, this value does not reflect the effectiveness of sodium polystyrene sulfonate, as the medication is not used to manage ammonia levels. Ammonia levels are more relevant in conditions affecting liver function, such as hepatic encephalopathy.
Choice D Reason:
A serum glucose level of 100 mg/dL is within the normal range (74 to 106 mg/dL). While it is important to monitor glucose levels, this value does not indicate the effectiveness of sodium polystyrene sulfonate. The medication’s primary function is to reduce potassium levels, not to manage glucose levels.