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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A Reason:
Bronchitis is a condition that affects the respiratory system, and while it is important to monitor, it is not a primary concern when administering phenylephrine. Phenylephrine is a decongestant that works by narrowing the blood vessels in the nasal passages, which can help relieve congestion but does not directly impact bronchitis.
Choice B Reason:
Diarrhea is a gastrointestinal condition that, while uncomfortable, does not significantly interact with phenylephrine. It is important to manage and monitor, but it does not pose a direct risk when taking phenylephrine.
Choice C Reason:
Hypertension is a significant concern when administering phenylephrine. Phenylephrine can increase blood pressure by causing vasoconstriction. For clients with hypertension, this can exacerbate their condition and lead to serious cardiovascular complications. Therefore, it is crucial to report this condition to the healthcare provider before administering the medication.
Choice D Reason:
Edema, or swelling, can be a symptom of various underlying conditions, including heart failure or kidney issues. While it is important to monitor, it is not as directly impacted by phenylephrine as hypertension. However, any underlying condition causing edema should be considered when administering medications.
Correct Answer is D
Explanation
Choice A Reason:
Nausea is a common side effect of many medications, including metoclopramide. While it is important to monitor, it is not the most critical adverse effect to report. Metoclopramide is often prescribed to manage nausea, so experiencing this symptom may indicate the need for dosage adjustment or additional supportive care, but it is not an emergency.
Choice B Reason:
Diarrhea is another common side effect of metoclopramide. It can be uncomfortable and may require management, but it is not typically life-threatening. The nurse should monitor the client and provide supportive care, but this side effect does not necessitate immediate reporting unless it becomes severe or persistent.
Choice C Reason:
Unusual irritability can occur with metoclopramide use. While it is important to note changes in mood or behavior, this symptom is not as critical as some other potential adverse effects. The nurse should monitor the client and consider discussing this symptom with the healthcare provider, but it is not the most urgent concern.
Choice D Reason:
Involuntary movements, such as those seen in tardive dyskinesia, are a serious adverse effect of metoclopramide. Tardive dyskinesia is a potentially irreversible condition characterized by repetitive, involuntary movements, often of the face and tongue. This side effect is significant and requires immediate reporting to the healthcare provider, as it may necessitate discontinuation of the medication and further evaluation.