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:
Determining the presence of abdominal pain is crucial because long-term use of ibuprofen can lead to gastrointestinal issues, including ulcers and bleeding. Abdominal pain can be an early sign of these complications, and prompt identification is essential to prevent more severe outcomes. Monitoring for gastrointestinal symptoms is a key aspect of managing patients on chronic NSAID therapy.
Choice B Reason:
While palpating the volume of pedal pulses is important for assessing peripheral circulation, it is not directly related to the potential side effects of long-term ibuprofen use. This assessment is more relevant for conditions affecting blood flow, such as peripheral artery disease, rather than for monitoring ibuprofen-related complications.
Choice C Reason:
Evaluating ongoing sleep patterns can provide valuable information about the client’s overall well-being and pain management. However, it is not the most critical assessment in the context of long-term ibuprofen use. Sleep disturbances may be related to chronic pain but are not directly indicative of ibuprofen’s adverse effects.
Choice D Reason:
Assessing back pain using a numeric scale is essential for evaluating the effectiveness of pain management strategies. However, it does not address the potential adverse effects of long-term ibuprofen use. While pain assessment is important, monitoring for signs of gastrointestinal complications takes precedence in this scenario.
Correct Answer is B
Explanation
Choice A reason:
Taking cimetidine an hour after antacids is appropriate because antacids can interfere with the absorption of cimetidine. It is recommended to separate the intake of these medications by at least one hour to ensure proper absorption and effectiveness of cimetidine.
Choice B reason:
Decreasing cigarette use to a pack per day is not sufficient for a client with peptic ulcer disease. Smoking has been shown to exacerbate peptic ulcers and hinder their healing process. Complete cessation of smoking is strongly recommended to improve the healing of peptic ulcers and reduce the risk of recurrence.
Choice C reason:
Monitoring for signs of sexual dysfunction is important because cimetidine can cause side effects such as decreased libido and erectile dysfunction. Patients should be aware of these potential side effects and report any issues to their healthcare provider.
Choice D reason:
Notifying the healthcare provider of lethargy is crucial because lethargy can be a sign of a more serious underlying condition or an adverse reaction to the medication. Prompt reporting allows for timely intervention and management.
