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:
Asking if the client is taking any supplements is important because certain supplements can affect blood urea nitrogen (BUN) levels. For example, high protein supplements can increase BUN levels, while others might interact with medications or affect kidney function.
Choice B reason:
Inquiring about itching or hives is relevant for identifying potential allergic reactions or side effects from medications or supplements. However, it is not directly related to the BUN levels.
Choice C reason:
Dry skin can be a symptom of various conditions, including dehydration or kidney issues. While it is a useful question, it does not directly address the BUN levels.
Choice D reason:
Asking if the client has noticed the need to urinate less often is crucial for assessing kidney function. Reduced urine output can indicate kidney dysfunction, which can affect BUN levels.
Choice E reason:
Using salt substitutes is relevant because some contain potassium, which can affect kidney function and electrolyte balance. This question helps assess potential dietary influences on BUN levels.
Choice F reason:
Experiencing urgency to urinate can be a symptom of urinary tract issues or other conditions. While it is important to know, it is not directly related to the BUN levels.
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.